TANIA RUIZ

• Conduct clinical reviews of outpatient services to determine medical necessity, appropriateness, and level of care in accordance with established criteria and organizational policies.
• Applied CMS, NCQA, and state regulatory standards to utilization decisions while ensuring adherence to HIPAA and confidentiality requirements.
• Documented utilization review determinations, clinical rationale, and authorization outcomes accurately in utilization management systems.

Adjust medical claim for denial or approval.

ICD10 and CPT coding.

Review medical records in accordance with HIPPA regulations.

Review service requests for completeness and ensure necessary clinical and non-clinical information is collected.

Prepare, document, and route cases into the appropriate systems for follow-up or clinical review.

• Cash handling
• Customer service