SIMONE L. WALLACE
CHARLOTTE
Summary
Seeking to secure a position that will enable me to use my problem solving and organizational skills. Also seeking to provide me with challenging targets and tremendous growth perspectives.
Overview
13
13
years of professional experience
Work History
Utilization Review Coordinator
Commonwealth Massachusetts
02.2025 - 09.2025
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Supervised and maintained all utilization review documentation through Altruista Health,Efax.
- Devise or identify solutions for irregular requests and issues.
- Performed prior authorization review of services requiring notification.
- Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
- Verified eligibility and compliance with authorization requirements for service providers.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Uploaded face sheets
- Reviewed Concurrent, Retro, and Discharge summaries.
- Performed various administrative tasks by filing, copying and faxing documents.
Insurance Verification Specialist
CareMetx
05.2024 - 02.2025
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Updated patient records with accurate, current insurance policy information.
- Achieved insurance pre-authorizations to enable timely patient procedures.
- Complied with HIPAA guidelines and regulations for confidential patient data.
- Proved successful working within tight deadlines and a fast-paced environment.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Specialty Pharmacy
- Outbound calls to various insurance payors
- Salesforce
- Reviewing copays, coinsurance and deductibles with payors.
Utilization Management Rep/Crisis Intake Specialist
Anthem/Carelon
01.2022 - 02.2024
- Refer members to In-Network Providers upon request.
- Determines Contract and Benefit eligibility.
- Provides authorization for inpatient admission, outpatient precertification, prior authorization, and retro request.
- ABA therapy, Substance Abuse, Grief, Eating Disorders, Inpatient Rehab, Intensive Outpatient Therapy, Partial-Hospitalization, Psych testing, Detox, SUD RTC, Telehealth, & General Outpatient.
- Crisis intervention phone request with members in need.
- Exercise judgement if one's safety is endangered.
- Provide Support to members feeling unsafe.
- Coordinate with CM if situation needs to be escalated to 911.
- Behavioral Health admissions via Fax, Email, Phone.
- Coordinates with inter-departmental associates as necessary.
- Conducts a thorough radius search in Provider finder and follows up with provider or referrals given.
- Conducts Clinical screening process
- Coordinates with Clinical Nurse to review necessary clinical for member.
- Responds to telephone and written inquiries from clients, providers, and in-house departments.
- Ensure proper CPT codes and ICD-10 are appropriately assigned.
- Process and handle denials and appeals as needed.
- Medicaid, Medicare, and commercial insurance knowledge.
- Ensured TAT was not missed.
- Verification of Providers Credentials.
Behavioral Health Billing & Collections A/R Specialist
Monte Nido & Affiliates
05.2021 - 11.2021
- Ensure timely and accurate processing of claims.
- Researched and resolved billing discrepancies to enable accurate billing.
- Determines Contract and Benefit eligibility.
- Updates corrected patient demographic and insurance information in the billing system.
- Verifies if authorization for inpatient admission, outpatient and post service request is needed.
- Coordinates and resubmits necessary PA forms required by all third-party payors.
- Coordinates with inter-departmental associates as necessary.
- Uphold and reinforce compliance with HIPAA.
- Utilize various databases, computer software, and EHS. (KIPU Software, Collaborate MD, Availity, Salesforce)
- Reports any reimbursement trends/delays to supervisor.
- Communicate with payors to clarify reasons for denials and identify necessary corrections.
- Follow up with payors via phone, fax, email, payor portals for Rejected claims.
- Utilize knowledge of state Medicaid, Medicare, and commercial insurance policies.
- Review and attach appropriate documentation for denied claims and submit appeals as necessary.
- Understanding Bill type and resubmission process.
- Correct and resubmit Denied claims.
- Knowledge of HCPC, ICD-10, and CPT codes
- Advise on procedural changes to implement and prevent future rejections.
- Review EOB
- Manage a workload of 40+ accounts daily.
- Comfortable working independently.
- (CONTRACT)
Phone Banking
Wells Fargo
09.2019 - 04.2021
- Loan applications, setting up/closing accounts, Credit Card applications.
- Wire Transfers
- Ensuring compliance with banking regulations and exceptional customer service.
- Loss prevention
- Product Knowledge
- Proactively prevent fraudulent activity.
- Support customers by utilizing solid verbal and written communication.
- Contact third parties for research.
Team Lead
WEC ENERGY GROUP
03.2015 - 09.2019
- Implement and maintain quality assurance processes.
- Monitor team performance against key metrics.
- Conduct regular performance evaluations and provide constructive feedback to team members.
- Identify trends to mitigate future issues.
- Onboard new call center agents along with company policies training.
- Time Management
- Advocate for customer needs and work to improve customer experience.
- Motivate and guide team toward achieving Metric goals.
- Generate reports on team performance including key metrics and customer satisfaction to present to higher management.
Medical Receptionist
Harris Behavioral Health Center
05.2012 - 12.2014
- Completed skilled administrative work to support all office staff and operational requirements.
- Appointment Scheduling
- EOB
- Payment Processing
- Emotional support
- Maintaining exam rooms when necessary
- Adhered to HIPAA guidelines.
- EHS
- Verifying Insurance /Benefits with Payors
- Patient Education
Education
High School Diploma -
Ashbrook High School
01.2009
Medical Assistant Certificate -
Kings College
Charlotte, NC01.2011
Skills
- Medical Terminology
- Claims processing
- Proficiency in Salesforce, Facets, Kipu, CMD, Aumi and Availity
- Research & trends Analysis
- ICD-9 AND ICD-10
- Medicaid, Medicare, Commercial Insurance Knowledge
- Microsoft Software's (Excel, Word, Outlook, Teams)
- Utilization management
- HIPAA compliance
Timeline
Utilization Review Coordinator
Commonwealth Massachusetts
02.2025 - 09.2025
Insurance Verification Specialist
CareMetx
05.2024 - 02.2025
Utilization Management Rep/Crisis Intake Specialist
Anthem/Carelon
01.2022 - 02.2024
Behavioral Health Billing & Collections A/R Specialist
Monte Nido & Affiliates
05.2021 - 11.2021
Phone Banking
Wells Fargo
09.2019 - 04.2021
Team Lead
WEC ENERGY GROUP
03.2015 - 09.2019
Medical Receptionist
Harris Behavioral Health Center
05.2012 - 12.2014
High School Diploma -
Ashbrook High School
Medical Assistant Certificate -
Kings College
Similar Profiles
Carol KazinskasCarol Kazinskas
Direct Support Professional at Commonwealth MassachusettsDirect Support Professional at Commonwealth Massachusetts
Jazmyn TaylorJazmyn Taylor
DDS Direct Care Worker at Commonwealth MassachusettsDDS Direct Care Worker at Commonwealth Massachusetts
Rogerio AlmasRogerio Almas
Commvault Data Protection Specialist at Commonwealth MassachusettsCommvault Data Protection Specialist at Commonwealth Massachusetts
Shawn RichardsonShawn Richardson
Deal Assurer at CiscoDeal Assurer at Cisco
Priya PatelPriya Patel
QC Technician at Prime Beverage GroupQC Technician at Prime Beverage Group