Kimberly Mejia

I’m a Healthcare Operations and Managed Care professional with 3+ years of experience supporting utilization management and prior authorization processing, eligibility determination, care coordination, provider relations, and regulatory compliance in complex managed care environments. I’m skilled in managing high-volume healthcare operations workflows, reviewing clinical and administrative documentation, coordinating cross-functional teams, and maintaining state, federal, and organizational requirements. I use systems including TruCare, DCMS, Macess, and PowerSTEPP to drive operational efficiency and documentation accuracy, including in remote environments.

In my recent roles, I manage service authorization workflows for prior authorizations and DME services, review eligibility/benefits coverage and utilization criteria, and research/resolution claims and authorization discrepancies through detailed documentation review. I also bring experience in eligibility determinations, audits, and quality reviews, and I’ve trained staff on workflow procedures and documentation standards. I’m motivated by quality assurance, smooth operational execution, and supporting healthcare delivery outcomes through compliant, well-organized processes.