Prior Authorization Specialist

Isabel Day

**** ********* **, *** **** Columbia, SC 29210 839*223*7017

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

Experience

Oct 2023- March 2024

Prior Authorization specialist

CVSHealth/Caremark

Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.

Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols

One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes

Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations

Establishes and maintains communication among health plan, and employer group staff

Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business

Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours availability as needed

July 2023- aUG 2023

Billing Coordinator EazeMedical Solutions

Meticulously prepared and submitted electronic and/or paper claims to various PPO, Workers' Compensation & Medicare payors utilizing NextGen, Phreesia and Daisybill software

Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments

Accurately read and interpreted explanation of benefits (EOB) from various workers' comp and private insurance payors

Communicated with insurance providers to resolve and/or re-submit appeals and denials

Negotiated & recovered all workers' comp past-due accounts

Review accident, injury reports and Doctors First Report forms to determine proper actions under Workers Compensation laws and regulations

Responsible for DME billing, negotiation & reimbursement issues of equipment and supplies for third party payment, i.e. pricing, codes, denial and resubmission criteria

Maintain a working knowledge of ICD-9/ICD-10 and CPT coding principles, coding guidelines, and third-party requirements regarding documentation and billing

Generate, typed, formatted and edited legal letters, documents and invoices

Interface with clients, medical, legal and insurance company professionals regarding claim status

Scheduled doctor appointments and client/doctor depositions

Posted all workers' compensation payments and maintained accounts through aged revenue reporting

Prevented financial delinquencies by working closely with department managers and providers to resolve billing issues before becoming unmanageable.

Orchestrated day-to-day operations of billing department, including medical coding, payment posting, accounts receivables and collections for private insurance payors

Feb 2023- June 2023

BCBS SC

Prior Authorization Specialist

Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.

Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols

One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes

Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations

Establishes and maintains communication among health plan, and employer group staff

Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business

Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours availability as needed

January 2022- February 2023

Performed freelance work with various companies in administrative, proofreading, editing, quality Assurance, and medical records/Research projects

June 2021 –December 2021

Associate Quality Control Specialist HDS/ROI Support Sharecare

Provides HIPAA, HITECH compliance by identifying all required elements and notating and informing customers or management (as required) of any exceptions

Maintains frequent communication to customer HIM departments and related personnel to maintain high quality release of information process

Develops and maintains strong customer relationships, ensuring high customer satisfaction

Develop and maintains an understanding of Federal and State medical record law, as well as general medical record terminology and management

Develop and maintain an understanding of company software and systems

Develop and maintain an understanding of customer EMR software and systems (maybe several). Able to meet or exceed daily productivity expectations with high quality and accurate output

Keeps Department Lead informed of concerns or issues regarding quality, connectivity, customer concerns, etc. that may inhibit

Sharecare HDS performance or service expectations for customers.

Produce periodic reporting as requested

Complete and maintain the AHIOS Certificate Program to become a Certified Release of Information Specialist.

November 2020 – May 2021

Residential Counselor New Hope Treatment Center

Assist in the orientation of new residents and provides continuing education and assistance with program rules and expectations.

Assist in the management of aggressive residents as needed, using only de-escalation and behavior management techniques approved by NHTC.

Assist in the coordination of therapeutic activities, and oversees the completion of regular activities including, but not limited to, hygiene, chores, journalizing, homework.

Using the approved NHTC format and prescribed intervals, accurately documents resident’s behavior, use of interventions, and the effectiveness of treatment plans.

Maintain an awareness of the whereabouts of all residents under their care by providing constant supervision, regular rounds, and resident counts throughout their shift.

Attend daily shift reports, staff meetings, resident staffing, and all other required meetings.

Participate in staff growth and development training activities and maintains a minimum number of hours as required by NHTC and managed care organizations.

Mar 2017 – September 2019

Developmentally Disabled Behavioral Therapist Monarch

Assess each person receiving services for their hopes, dreams, desires, provide supports

that facilitate achievement.

Support people who have been identified as extremely aggressive, and violent and who have demonstrated a consistent pattern of life-threatening aggression against staff, law enforcement officials and/or others in the community.

Ensure that the rights of each person receiving services are protected and always promoted.

Assist people in developing advocacy skills, participating in advocacy efforts, and utilizing personal advocates.

Facilitate person-centered, effective, positive relationships with people receiving services using positive approaches that promote self-determination in all areas of life.

Facilitate access to community resources, including locating recreational activities, housing, food, clothing, school programs, vocational opportunities, or services providers to teach life skills, and relevant mental health, developmental disabilities, and substance abuse services.

Assist person supported to develop resources and assist in the pursuit to maintain contact with social support networks.

Manage caseload of 8 patients with substance dependence and co-occurring Axis I and Axis II disorders. Train inexperienced staff and/or current staff with orientation, mentoring, and trainings.

April 2015 –September 2018

Certified Medical Assistant NOVA Urgent Care

Gather patient medical history, taking and recording vital sign information, and occasionally assisting with minor, office-based procedures.

Scribe, vitals, labs, phlebotomy, suturing, casting, billing & coding, transcription, general office duties.

Communicate clearly and effectively with patients to verify information, determine purpose of visit and record medical history.

Implemented care and efficiency improvements to support and enhance office operations. Supported duties for diagnostic and technical treatment procedures, such as setting up and operating special medical equipment and apparatus.

Collaborated with medical and administrative personnel to maintain patient-focused, engaging, and compassionate environment.

Educated patients by providing medication and diet information and clarifying physicians' orders, answering questions thoroughly. Explained procedures to patients to reduce anxieties and increase patient cooperation.

Maintained detailed records of test results by entering data and patient information into the computer.

Enhanced positive patient outcomes by providing knowledgeable education on procedures, medications, and other physician instructions. Prepared patients for X-rays, electrocardiograms, suture removal, and dressing changes.

Completed clinical procedures and gathered patient data for interpretation by physicians. Collected and documented patient medical information such as blood pressure and weight. Prepared blood, urine, stool, and sputum lab specimens for diagnostic evaluation

Performed clerical duties, such as word processing, data entry, answering phones, and filing. Performed billing, coding, and file maintenance for entire patient load.

Assisted physicians in follow-through care.

Obtained all prescribed laboratory testing.

Submitted prescriptions to pharmacy via phone, fax, or escribe.

Education

AHIOS

CRIS Certification: ROI Specialist, December 2021

Pamlico Community College, Grantsboro, NC

NC State Certification: EMT Basic, May 2019

AAS Medical Assisting, May 2013, 3.58 GPA

Certification: Phlebotomy, Laboratory Technology, Medical Office Administration, Medical Billing

& Coding, Microsoft Office Suite, Medical Terminology, Medical Transcription, Sept 2009- May 2013

ACT WorkKeys Career Rediness Assessment Certifications November 17, 2010

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