ShaTonya Ervin
Jackson
Summary
Detail-oriented and results-driven Utilization Management Specialist with over 4 years of experience in healthcare utilization review, case management, and compliance monitoring. Adept at analyzing clinical documentation, coordinating with interdisciplinary teams, and ensuring adherence to medical necessity and regulatory standards. Proven ability to improve care coordination while maintaining cost-effectiveness and quality of service. Experience in multiple specialties including: General Surgery (inpatient & outpatient), Sports Medicine, Dermatology, OBGYN, Family Medicine, Radiology, Infusion services, etc. Experience working in office, clinical, and hospital environment.
Overview
5
5
years of professional experience
Work History
Utilization Reviewer
Vital Care Infusion Services
10.2023 - 04.2025
- Conduct concurrent and retrospective utilization reviews for inpatient and outpatient services.
- Evaluate clinical records to determine the appropriateness of admissions, continued stay, and discharge.
- Collaborate with providers, case managers, and physicians to streamline patient care and manage cost-effective services.
- Apply InterQual and/or Milliman guidelines to support medical necessity reviews.
- Prepare and submit clinical documentation for appeal processes when necessary.
- Document determinations and communications in accordance with organizational protocols and compliance standards.
Utilization Management Specialist
UTRGV
06.2022 - 10.2023
- Reviewed patient cases for appropriate level of care, including inpatient, observation, and skilled nursing.
- Coordinated with multidisciplinary teams to develop and execute discharge plans.
- Reduced unnecessary hospital stays by 15% through effective case intervention strategies.
- Utilized EMR systems (Epic, Athena) to track patient outcomes and maintain accurate records.
- Educated staff and patients on healthcare coverage, referrals, and post-acute care resources.
HC & Insurance Operations Senior Rep
NTT Data Services
12.2022 - 09.2023
- Verified eligibility and compliance with authorization requirements for service providers.
- Tracked referral submission during facilitation of prior authorization issuance.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- 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.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
Care Manager
Allcare Plus Pharmacy
04.2022 - 06.2022
- Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for patients.
- Maintained detailed records in compliance with agency standards and regulations.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Scheduled surgeries, managed pre-certifications and verified insurance coverage.
Insurance Verification Specialist
AmerisourceBergen
10.2020 - 04.2022
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Achieved insurance pre-authorizations to enable timely patient procedures.
- Complied with HIPAA guidelines and regulations for confidential patient data.
- Updated patient records with accurate, current insurance policy information.
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Supervised and maintained all utilization review documentation through Epic.
Education
Career Diploma - Electronic Medical Records
Ashworth College
Online10-2020
Career Diploma - Medical Billing And Coding
Penn Foster Career School
Online12-2011
MBA - Business Administration And Management
University of Phoenix
Online05-2011
Bachelor of Science - Business Management
Everest University
Online05-2009
Skills
- Utilization Review & Case Management
- Interdisciplinary Collaboration
- Medical Necessity Determination
- Regulatory Compliance (CMS, NCQA, URAC)
- Electronic Medical Records (EMR/EHR)
- Pre-authorization & Denial Management
- Quality Assurance & Risk Management
- ICD-10 & CPT Coding
- HIPAA Compliance
Timeline
Utilization Reviewer
Vital Care Infusion Services
10.2023 - 04.2025
HC & Insurance Operations Senior Rep
NTT Data Services
12.2022 - 09.2023
Utilization Management Specialist
UTRGV
06.2022 - 10.2023
Care Manager
Allcare Plus Pharmacy
04.2022 - 06.2022
Insurance Verification Specialist
AmerisourceBergen
10.2020 - 04.2022
Career Diploma - Electronic Medical Records
Ashworth College
Career Diploma - Medical Billing And Coding
Penn Foster Career School
MBA - Business Administration And Management
University of Phoenix
Bachelor of Science - Business Management
Everest University
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