EDNA LIPKE
Lincoln
Summary
Accomplished healthcare operations specialist with 15+ years of experience in care coordination, inpatient and outpatient utilization management, and authorization and referral processing. Proficient in medical terminology, chart analysis, record tracking, and data abstraction. Adept at optimizing workflows while ensuring full compliance with CMS and health plan standards. Experienced in claims review, verification, and processing within healthcare operations. Self-motivated and dependable, thriving in both team-based and independent work environments. Experienced in insurance verification and eligibility determination.
Overview
17
17
years of professional experience
Work History
Utilization Management Coordinator
Alignment Healthcare
09.2025 - Current
- Reviews and verifies authorizations for accuracy and completeness.
- Conducts daily outreach calls to hospital facilities to verify patient admission or discharge status and documents findings per UM guidelines.
- Creates patient cases from received fax documents as needed, ensuring accurate data entry and compliance with UM documentation and turnaround standards.
- Processes and coordinates post-discharge service cases, including home health, DME, and ambulance arrangements.
- Sends fax correspondence to hospitals and IPAs regarding patient admissions, providing notification of inpatient status.
- Sends fax requests to facilities to obtain clinical and discharge information.
- Reviews and verifies member insurance coverage and eligibility to ensure requests and authorizations were processed in compliance with plan requirements.
Care Management Support Coordinator IV
Health Net Federal Services
09.2015 - 02.2025
- Identified potential discrepancies, errors, or inefficiencies and worked proactively to resolve them.
- Verified patient insurance coverage and eligibility, ensuring accurate billing and compliance with payer requirements.
- Maintained high accuracy while consistently meeting and exceeding daily data entry quotas in a high-volume environment.
- Partnered with compliance and quality teams to maintain URAC audit readiness through accurate utilization management documentation and support of internal audit activities.
- Monitored authorization timelines and turnaround times to prevent delays.
- Collaborated with UM clinicians to escalate requests requiring additional clinical review.
- Sent fax correspondence to facilities regarding beneficiary authorizations.
- Utilized the PGBA claims system to cross-reference authorizations and claims, verifying date of service, provider details, and procedure codes, and updated system records as needed.
- Conducted provider outreach calls to obtain required information for processing referrals and authorizations.
- Created and maintained authorization cases by accurately entering data into relevant systems, ensuring compliance and timely coordination of services to support patient care.
- Sent daily inventory reports to management and reported Provider Directory discrepancies for correction.
- Assisted with routine referral/authorization case audits to ensure documentation compliance and conducted productivity audits for CMAs.
- Coordinated workflow and supported productivity of Care Management Assistants (CMAs).
- Assisted with training of new team members as needed.
Case/Care Management Assistant
Health Net Federal Services
06.2015 - 09.2015
- Prioritized and processed referral and authorization requests accurately and within required turnaround standards.
- Delivered eligibility and coverage determinations to beneficiaries and providers via mail and fax correspondence.
- Monitored authorization status and collaborated with providers to obtain missing information.
- Performed insurance coverage and eligibility verification to support timely and accurate processing of service requests and authorizations.
Disease Management Assistant
Health Net Federal Services
Rancho Cordova
06.2012 - 06.2015
- Assisted Disease Management team with daily operations, including handling correspondence, scheduling, and administrative tasks.
- Coordinated Disease Management clinician calendars and beneficiary appointments.
- Performed outbound reminder calls to beneficiaries regarding scheduled appointments.
- Built Excel reports and tracking systems to improve team efficiency.
Intake Representative II
Health Net Federal Services
Rancho Cordova
03.2009 - 06.2012
- Entered and managed referral and authorization requests from Military Treatment Facilities (MTFs) and civilian providers in Medical Management System (MMS).
- Investigated and resolved high-priority authorization issues requiring detailed review.
- Performed quality checks on referrals and authorizations, redirecting beneficiaries to network providers as appropriate.
- Verified insurance coverage and eligibility to ensure accurate and timely processing of authorizations and service requests.
Education
High School Diploma -
Copper Hills High School
West Jordan, UTGeneral Studies Coursework -
Salt Lake Community College
Salt Lake City, UTSkills
- High Volume Data Entry
- Insurance/Eligibility Verification
- Claims Review & Processing
- CMS Compliance
- HIPAA Compliance
- URAC Compliance
- CPT Coding
- ICD 10 Coding
- Auditing
- IPA Operational Knowledge
- HMO Operational Knowledge
- Inpatient Authorization
- Outpatient Authorization
- Referral Processing
- Administrative Support
- Clerical Support
- Team Leadership
- Excel Reporting
- Quick to Learn
- Adapt to Change
- Independent
- Team-Oriented
- Accurate Data Entry
- Precise Documentation
- Follows Written Instructions
- Follows Oral Instructions
- Follows Diagrammed Instructions
- Navigating Computer Systems
- Managing Computer Systems
- EMR/EHR
- EPIC
- Microsoft Office Suite
- Microsoft Windows
- SharePoint
- Teams
- Zoom
- MMS
- DEERS
- PGBA System
- DOMA
- CareRadius
Accomplishments
- Advanced to Lead position in the Inpatient UM department within three months of hire.
- Assisted in reviewing and implementing policies and procedures in the Inpatient UM department.
- Maintained perfect attendance record and consistently praised for initiative and reliability.
- Advanced to Specialty Team (Non-Net) and served as backup Team Lead for escalated cases.
Training
- Additional Training in Medical Terminology and CPT/ICD-10 Coding
- HIPAA Compliance Training
- Additional Experience Assisting with URAC Accreditation Preparation
Timeline
Utilization Management Coordinator
Alignment Healthcare
09.2025 - Current
Care Management Support Coordinator IV
Health Net Federal Services
09.2015 - 02.2025
Case/Care Management Assistant
Health Net Federal Services
06.2015 - 09.2015
Disease Management Assistant
Health Net Federal Services
06.2012 - 06.2015
Intake Representative II
Health Net Federal Services
03.2009 - 06.2012
High School Diploma -
Copper Hills High School
General Studies Coursework -
Salt Lake Community College