Branden Gray-Jefferson

• Performs intake of calls from members or providers regarding services via telephone, fax, EDI.

Utilizes eTUMS and other Aetna system to build, research and enter member information.

Screens requests for appropriate referral to medical services staff.

Approve services that do not require a medical review in accordance with the benefit plan.

Performs non-medical research including eligibility verification, COB, and benefits verification.

Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.

Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively)

Protects the confidentiality of member information and adheres to company policies regarding confidentiality Communicate with Aetna Case Managers, when processing transactions for members active in this Program Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.

Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations. Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.

Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.

Sedentary work involving significant periods of sitting, talking, hearing and keying.

Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.

• Under the direction of a shared Facility Health Information Management Leader, the Facility HIM Coordinator assist as needed in the day-to-day HIM departmental clerical activities, including but not limited to working the Horizon Patient Folder (HPF)/McKesson Patient Folder (MPF) workflow queues, resolving unbilled accounts, facilitating the physician suspension process. The Facility HIM Coordinator will serve as the on- site initial point of contact when the HIM Leader is off-site for the Facility Leadership and the Medical Staff.
• Ensure facility based HIM function productivity and quality standards are maintained or exceeded
• Assist the HIM Leader with Facility Privacy Officer (FPO) duties, Records Management duties, and employee training and development
• Assist Facility HIM Clerks and Birth Certificate Clerks with questions
• Enter applicable unbilled reason codes (URCs) into HPF and MEDITECH on a daily basis
• Adhere to documented and established workflow guidelines as it relates to managing facility HPF/MPF work queues and 3M 360 Encompass worklists
• Assist in the processing of walk-in requests for Release of Information
• Request and return paper records from off-site storage as applicable
• Retrieve discharged medical records from various nursing units and ancillary departments as needed
• Assist in reconciling retrieved medical records against patient discharge listings working closely with patient care units to ensure receipt of all records no later than the morning after discharge or visit
• Assist physicians in record completion activities

• Process initial EHR, EMR record requests including; printing pull lists, requesting letters and coversheets, photocopying of materials, scanning mailing labels, packing initial request envelopes with all required documents, and mailing via postage meter and U.S. Postal Service. Adjudicates ADR for TS/MRS and CMS upon request. Sets up new users and resets passwords for MAC users to access the CERT Website. Process the medical records and appeals requested by Macs. Process MAC Accuracy project. Tech support CMS users with usernames, and password resets.

• Communicate with other healthcare professionals to clarify correct person, or to obtain additional information. Assist with identifying fraud, and waste for medicare and medicaid claims. Maintain electronic health records (EHR) databases such as Smart Doc, (it's an Intelligent Document Capture System which automates the intake and classification of medical records). Advance Case Track. Work with analysts, and nurses to clarify information, and may assist with other office duties such as boxing, labeling, and stocking. Capture - as a Medical Records Technician I intake pages of medical records from a variety of sources via electronic and paper formats and transform the information into meaningful data. Hardcopy medical records are converted into digital format through high-speed scanners. Our department processed 6 million records in 2017. Classification & Categorization - the system was designed with automated classification technology capable of recognizing up to 50 document types. The system utilizes Optical Character Recognition (OCR) technology. It runs OCR on each document page, extracts the data and categorizes medical records by the 50 document types, service date and beneficiary. As a Medical Records Technician I assist the machine in learning additional document types and classifications to continually improve classification accuracy. Data Extraction - the system automatically extracts fields for each medical record. Validation - as a Medical Records Technician I validate and make corrections as needed on the auto extracted fields. This ensures the data was extracted correctly; which provides a high level of confidence.Delivery - medical records are available to reviewers already categorized and organized saving the reviewers up to 15% review time.

• Consumer Directed Service and financial industry. Assisting consumers, members, or recipients with their Attendant or Respite taxes, payroll, time sheets, enrollment, waiver codes (940, 902, 900), and correct waiver type (EDCD - elderly or disabled, IFDDS- individual and elopement disabilities, ID waiver- intellectual disability, MR waiver- mental retardation, and Aged waiver- elderly and disable). Coverage in the states of VA, PA, WV, and CO for programs, such as Medicaid, Medicare, and MCOs. Processing the authorization, and eligibility of each member through software such as Portal (where support tickets are created, worked, and completed), Access (tracking of tickets, and production), Excel (pulling ADHOC reports of enrollment), Outlook (communicating with plans). Navison (main system of information), MMIS (Manpower Management Information System). HETS 270/271 changes for ANSI X12 5010A1. Contacting CPS (Client Provider Services) to reach out to the EOR (Employer of Record), SF (Service Faciliator), and DMAS (Department of Medical Assistance).

• Responsible for planning, monitoring and alerting management of any issues related to workflow and processes. Responsible to assist Medical Records Processing Center Manager in training and implementing workload changes as needed. Responsible to alert the Medical Records Processing Center Manager of potential personnel issues that need to be addressed. Manage, maintain and organize patient health-care records. Organize and manage patients' health information data. Ensure paperwork is properly filled out. Verify accuracy and accessibility of files. Ensure all files are secure.

• Communicate with other healthcare professionals to clarify correct person, or to obtain additional information. Assist with identifying fraud, and waste for medicare and medicaid claims. Maintain electronic health records (EHR) databases such as Smart Doc, (it's an Intelligent Document Capture System which automates the intake and classification of medical records). Advance Case Track. Work with analysts, and nurses to clarify information, and may assist with other office duties such as boxing, labeling, and stocking. Capture - as a Medical Records Technician I intake pages of medical records from a variety of sources via electronic and paper formats and transform the information into meaningful data. Hardcopy medical records are converted into digital format through high-speed scanners. Our department processed 6 million records in 2017. Classification & Categorization - the system was designed with automated classification technology capable of recognizing up to 50 document types. The system utilizes Optical Character Recognition (OCR) technology. It runs OCR on each document page, extracts the data and categorizes medical records by the 50 document types, service date and beneficiary. As a Medical Records Technician I assist the machine in learning additional document types and classifications to continually improve classification accuracy. Data Extraction - the system automatically extracts fields for each medical record. Validation - as a Medical Records Technician I validate and make corrections as needed on the auto extracted fields. This ensures the data was extracted correctly; which provides a high level of confidence.Delivery - medical records are available to reviewers already categorized and organized saving the reviewers up to 15% review time.

• Initiated medical record by searching master patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physicians' offices for information verification; processing or creating the record folder. Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintaining chart location systems. Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records; notifying medical director of physicians in jeopardy of losing admitting privileges. Resolves medical record discrepancies by collecting and analyzing information. Maintains patient confidence and protects hospital operations by keeping information confidential; following release-of-information protocols.
• Onbase (St. Francis), Rcom, Artiva, Rebill, HOST, Microsoft Office Outlook, Word, Excell, Powerpoint, HPF (work and web station), Concuiy, Meditech (St. Francis)