Healthcare eligibility & authorizations rep, Data Entry, Customer Svc

Kennetha L. Williams

**** ******* ** **** #** * San Antonio, TX 78245 * 832-***-**** *

********.********@*****.***

Dedicated, results-oriented professional with extensive experience in all aspects of customer service including customer relations, billings and collections; Complaints and grievances; Special talent for building strong relationships with customers and employees; Effective team member who is comfortable leading or collaborating; Strong problem-solving, leadership and communications skills. KEY SKILLS

● Customer Service Experience

● Data Entry Skills

● Billing and Accounting Skills ● Advanced Secretarial Skills

● Microsoft Word, Excel, Power Point

● 40+ WPM

● Assist with multiple services including:

customer/member support, verifying

insurance/eligibility, scheduling

● Processing Prior Authorizations/Appeals

● ICD-9/ICD-10

● Complaints

Resolution/Member

Advocate

WORK EXPERIENCE

Eligibility Coordinator - Remote

VitalCaring Group

July, 2023 - Current

● Verifies insurance coverage and benefits for agency patients and communicates non-coverage to the Branch as soon as possible.

● Completes workflow tasks and other assignments in the Agency's electronic medical recording a timely manner.

● Uploads payor communication documents into the EMR, as needed, utilizing company guidelines for document naming conventions and attachment types.

● Inputs insurance verification related Coordination Notes into the EMR to assist in effective communication with Branch administrative staff members.

● Promotes the company philosophy, values and mission by presenting a positive image tothose we serve including patients, families, physicians, vendors and community agencies in word, action and appearance

● Assists with communications which may include: taking incoming phone calls for the department documenting and disseminating messages as appropriate, handling emails for the department, distributing mail or documents as appropriate to the department and appropriate leaders.

● Provide effective communication to patient/family, team members, and other health care professionals and maintains confidentiality per HIPAA regulations and company guidelines

● Works with great urgency and accuracy to complete tasks within strict turnaround time guidelines.

Prior Authorization Representative - Remote

Envision Radiology

April 2022 - July, 2023

● Notifies insurance companies of services being rendered, and obtains any necessary authorizations, ensuring notification and verification is complete for each order.

● Obtains and verifies any necessary additional demographic and/or billing information.

● Assists in identifying authorization issues and ensures that insurance information has been accurately obtained.

● Works daily queues according to department directives to ensure all payer-specific authorization requirements are met and authorizations successfully obtained while consistently meeting department productivity standards.

● Provides quality customer service to all patients and customers through prompt and courteous professional communication.

● Interfaces with provider's offices and medical staff to ensure all necessary documentation is obtained for purposes of pursuing a successful authorization approval.

● Documents accurately into the Electronic Medical Record (EMR) system all actions, interactions, and authorizations surrounding the insurance process for each patient.

● Participates in peer-to-peer learning and development. Prior Authorization Representative-Medicare-Work From Home CVS Caremark - San Antonio, TX

September 2021 - April 2022

● Working incoming cases via phone (primarily) or fax to process coverage requests from members or prescribers

● Conducting outreach to patients and providers, and obtaining additional information needed to process requests

● Researching and correcting any issues found in the overall process

● Raising issues to Coverage Determination Clinical Pharmacists and Management team as needed

● Reading, analyzing, and interpreting general business correspondence, technical procedures, and governmental regulations

● Solving practical problems and dealing with multiple concrete variables in standardized situations

● Performing basic mathematical calculations

● Ensuring all cases are properly closed

● Ability to interpret a variety of work instructions provided through multiple mediums

● Ability to anticipate needs and resolve issues with urgency and to meet quality and production standards

● Schedule flexibility including rotations through Nights, Saturdays and minimal Holiday Coverage

Prior Authorization Coordinator

Phyz Healthcare Solutions - San Antonio, TX

December 2020 to August 2021

● Confirm accurate and timely completion of prior authorizations to the insurance payers utilizing the OPS portal, CoverMyMeds, and necessary platforms.

● Accurate and timely completion of appeals and clinical paperwork for physician offices.

● Send all updates/forms to physician and payer for necessary completion.

● Follow up on all claims requiring prior authorization within 1-2 business days.

● Utilize proprietary software to manage workflow and patient notifications.

● Reviews proprietary software for workflow and tracking of open prior authorizations, appeals and expiration dates.

● Follow the standards within the Policies & Procedures manual. Program Coordinator I

Centene/Superior Healthplan San Antonio, TX

10/2020 - 12/2020

● Assist in activities related to the medical and psychosocial aspects of utilization and coordinated care.

● Initiate authorization requests for output or input services in keeping with the prior authorization list. Research claims inquiry specific to the department and responsibility.

● Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results. Assess and monitor inpatient census.

● Screen for eligibility and benefits. Identify members without a PCP and refer to Member Services. Screen members by priority for case management (CM) assessment. Perform transition of care duties to include but not limited to, contact the member’s attending physician, member or medical power of attorney, other medical providers (home health agencies, equipment vendors) for information pertaining to special needs.

● Coordinate services with community based organizations. Attend marketing and outreach meetings as directed to represent the plan. Produces and mails routine CM letters and program educational material.

● Data enter assessments and authorizations into the system. Surgery Scheduler

HCA/Methodist Health System San Antonio, TX

02/2020 - 10/2020

● Responsible for the scheduling of phone and faxed request in a prompt and courteous manner.

● Manage difficult and interdepartmental scheduling with minimal delay to customer.

● Correct utilization of the scheduling features of Meditech system and accurately enter all mandatory information.

● Provides instructions to patients and physician’s staff on test preparation and registration information. Establish and maintain a working knowledge and vocabulary of procedures scheduled.

● Manage daily operations including but not limited to: Meditech, Orders Management System, Call Center Equipment (phones, etc.), fax machines, printers. Precertification/Eligibility and Benefits Specialist Consultants In Pain Medicine Dr. Shaun Jackson, San Antonio, TX 01/2020 - 01/2020

● Review insurance policy to determine medical coverage criteria has been met for a specific procedure.

● Obtain authorization from insurance companies or adjusters for specific procedure or patients.

● Provide customer service, such as limited instructions on proceeding with claims or referrals, to expedite payment of claims.

● Obtain over the phone an online approval or records.

● Enter authorization or approval information related to patient in the patient medical chart.

● Coordinate peer review or pre-determination with the insurance representatives / companies and the providers.

● Contact insured or other involved persons to obtain missing information.

● Obtain certification from insurance carrier or Third-Party Administrator for approval to perform service or provide product

● Contact health insurance carrier or Third-party administrator regarding coverage for claims processing.

Complaint & Appeal Analyst

Aetna Healthcare, San Antonio, TX

09/2015 - 01/2020

● Responsible for managing to resolution complaint/appeal scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units.

● Ensure timely, customer focused response to complaints/appeals.

● Identify trends and emerging issues and report and recommend solutions.

● Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure

● Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements

● Verify eligibility requirements and benefits with physicians and health care professionals for Medical/Prescription Medicare and Medicare Advantage healthcare services Customer Communications Specialist

Coventry Healthcare (now Aetna Healthcare), San Antonio, TX 10/2010 - 09/2015

● Interfaces with customers via telephone, written correspondence, fax, web, and/or electronic mail to respond to routine inquiries and resolve concerns for Medicare Part D (prescription) and Part C (medical) members

● Maintains complete and accurate documentation of all customer interactions

● Demonstrates responsiveness and urgency when dealing with customers; Demonstrates a basic understanding of all products

● Supports individual and team goals; accepts ownership for individual results

● Demonstrates professionalism and presents a positive image of the company when interacting with customers

EDUCATION

Abraham Lincoln High School, Port Arthur, TX

08/1996 to 05/2000

High School Diploma

Lamar State College, Port Arthur, TX

08/2000 to 08/2001

Information Technology

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