Emergency Department Authorization Specialist

Shawna McClary

P.O. Box ***** Pittsburgh, PA ****5

412-***-**** ad5xpe@r.postjobfree.com

EXPERIENCE

UPMC

Sr Authorization Specialist Pittsburgh, Pa

March 2019-Present

● To perform authorization activities of inpatient /outpatient and Emergency department patients,patients, denial management/all revenues

● Reviews and interprets medical record documentation for patient history, diagnosis and previous treatment plans to pre-authorize insurance plan determined procedures to avoid financial penalties to patient, provider and facility

● Ensures accurate coding of the diagnosis, procedure, and services being rendered using ICD-9,10 CM,CPT and HCPCS level II, reimbursement controls,medical terminology

,pathology,22-modifiers,sox coding

● Works collaboratively with internal and external contacts specifically, Physician Services and Hospital division across UPMC as well as payors to enhance customer satisfaction and process compliance, ensuring the seamless coordination of work and to avoid a negative financial impact

● Resolves basic authorization edits to ensure timely claim filing and elimination of payor rejections and or denial,submitting appeal thru payor portals or sending thru mail via fax or thru Epic, navinet, availty,

● Utilizes payor-specific approved criteria or state laws and regulations to determine medical necessity or the clinical appropriateness for inpatient admissions, outpatient facility, office services, durable medical equipment, and drugs in terms of type, frequency

,extent,site and duration, and considered effective for the patient’s illness, injury or disease.

Pittsburgh, PA

Account Representative Sr. August 2016 to March 2019

■ Ensure the timeliness and accuracy of billing, collections, contractual postings, payments and adjustments of accounts based upon their functional area standards.

■ Verify accuracy of payment posting and reimbursement. Work with appropriate payer and/or department to resolve any payment discrepancies.

■ Demonstrate the ability to recommend corrective action steps to eliminate future occurrences of denials. Assist in claim appeal process and/or perform follow-up United Healthcare Pittsburgh, PA

Provider Data Specialist February 2012 to August

2016

■ Maintains current provider data and database, reporting and extracting data for various reports and analyses

■ Manages communication processes with other departments regarding database improvements

■ Develops and maintains standards for database integrity and quality assurance while conducting audits and providing feedback to reduce errors and improve processes and performance

UPMC Pittsburgh, PA

Provider Advocate January 2011 to February

2012

■ Provided information regarding claim status, provider payments, appeals and member eligibility

■ Addressed customer service inquiries in a timely and accurate manner

■ Built customer loyalty by placing follow-up calls for providers who reported product issues

■ Assist with adjustments in accordance with company policies and procedures. Golden Living Center Pittsburgh, PA

Medical Insurance Biller April 2006 to January 2011

■ Work claims and claim denials to ensure maximum reimbursement for services provided

■ Perform posting charges and completion of claims to payers in a timely fashion

■ Checking eligibility and benefits verification for treatments, hospitalizations, and procedures.

■ Called insurance companies regarding any discrepancy in payments if necessary H&R Block Pittsburgh, PA

Tax preparer/Receptionist August 2003

1to April 2021

■ Responsible for greeting clients and assisting authorized personnel with locating information

■ Responsible for filling and responding to customer inquiries

■ Informing clients or employers on the process

■ Collecting relevant documents information pay stubs w-4 or any other income/receipts/tax forms, expenses

■ Inputting data from financial records into tax return software or databases

■ Using applicable federal, state and local tax laws to determine deductions and how much each client will pay or earn on the return

■ Completing and filling tax documents with appropriate agencies, like IRS,state and local government

■ Building customer relationships to promote and expand the business EDUCATION

Carlow University January 2015-August 2018

Bachelor of Science in Management in Health Service Community College of Allegheny County June 2002 -May 2006 Associate of Computer Science

Albright University August 1998-May 2001

Allied health in Physical Therapy

Oakland Catholic High School August 1994-May 1998

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