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Nurse Insurance

St Louis County, Missouri, United States
August 19, 2018

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Dedicated Prior Authorization Representative with advanced-level skills in communication with insurance companies and knowledge of criteria needed for obtaining authorizations for servicess. Prepared to offer 19 years' experience working with clinical departments and insurance companies to obtain the authorizations for services. Organized, detail oriented and efficient with the capacity to multi-task.

Quick learner

Time management skills

Excellent communication skills

Detail oriented

Ability to prioritize workload

Microsoft Office

Computer knowledge

Documentation oriented

CPT code and ICD-10 code knowledge

Medical terminology

06/1999 to 07/2018


St. Louis, MO

Prior Authorization Representative

Worked directly with 5 of 16 teams of Doctor, Nurse and Medical Assistants to handle the prior authorizations of their patients.

Contact the patients insurance company via outbound calls, online websites or fax to obtain authorization for their medical procedure, test, surgery, inpatient admission, 23 hour admission, DME product, injections, pharmaceutical needs or physical/occupational therapy.

Verified all patient benefits and eligibility prior to the procedure being done. Contacted Workers Compensation adjustor or Nurse case manager for approval for procedures for work comp accounts.

Communicated all approvals and /or denials to the teams and the facility where procedure is to be performed. Provided all clinical information and any prior authorization forms needed to meet criteria for approval to the insurance companies via fax, upload on website if that option is available and /or verbally within the appropriate time frame requested by the insurance company.

Scheduled peer to peer determinations with the insurance company's Medical Director and the ordering physician. Documented all communications whether via fax, mail, phone conversation or online into the patients account by computer.

Maintained a high level of professionalism when speaking to the doctors and insurance companies. Communicated insurance authorization issues with patients to try to find an effective resolution. Attended any meetings regarding the prior authorization department for changes within the department and/or any upcoming changes with insurance plans authorization requirements. Worked with patient information, upholding the HIPPA regulations and following all company policies regarding patient confidentiality.

Worked on a dual screen computer for multi-tasking workload and prioritizing work. Worked with CPT coding of procedures and surgeries and ICD-10 codes. Knowledge of coding books and able to look up codes as needed. Knowledge of medial terminology

Called facilities to schedule procedures, test or surgeries. Faxed orders to facilities once procedures or surgeries were scheduled. Worked with physicians in clinical capacity rooming patients, taking patient history, vitals, setting up for x-ray, administering casts and removal of casts, drawing up medications for injections and communication with patient, physician and clinical staff.

06/1996 to 07/1998


Chesterfield, MO

LPN Charge Nurse

Charge Nurse on skilled nursing floor at a nursing home. Worked with a team of 3 nurse assistants and 1 Certified medication technician. SUMMARY



Gave daily report of residents to staff and monitored their care of residents. Administered, directed and coordinated the care of the residents during my shift. Administered medications, started IV therapies and continued IV medications. Coordinated residents meal time, supplements and snacks. Managed wound care, gave respiratory treatments, tube feedings and any other treatment residents had ordered. Documented resident information in resident charts accordingly. Documented new resident intake information, handle the admission paperwork and resident/family orientation to the facility, floor and staff.

Placed calls to residents primary physician for orders pertaining to residents continued care. Handled all emergency situations when resident needed to be transferred to hospital for emergency care. Handled all discharged residents paperwork and belongings. ASSOCIATE OF SCIENCE: NURSING 1993

Jefferson College, Hillsboro, MO

Yearly Outstanding Employee Dedication Certificates for 19 Years EDUCATION AND TRAINING


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