Customer Service Authorization Associate
Resume:
AND
Lavern A Buford
Preferred Name: Toni
Lithia Springs, GA 30122
ad5xt5@r.postjobfree.com
678-***-**** cell
OBJECTIVE
• To use my years of experience in the healthcare industry to secure/obtain a responsible career opportunity to fully utilize my training and skills, while making a significant contribution to the success of the company.
SUMMARY OF QUALIFICATIONS
• Twenty plus years of concurrent outpatient/inpatient approvals experience, including as an Inpatient Insurance Specialist Authorization Representative
• Front offices lead in a medical field.
• Proven speaking, communication, and interpersonal skills
• Twenty years of customer service
PROFESSIONAL EXPERIENCE
PIEDMONT HEALTHCARE-Atlanta/Vinings, GA
Patient Connection Authorization Associate II
Patient Connection Prep-Verification/Authorization Associate I April 2018 – Present
• Serves as front line support for the Patient Connection Center within Piedmont Healthcare
• Reviews orders for outpatient hospital services to ensure completeness pprior to scheduling
• Prepares for the patient visit by verifying patient insurance, confirming benefits, determining authorization requirements
• Reviewing medical necessity and creating patient liability estimates
• Calculates and determines financial responsibility for patients including deductibles, co-payments and amounts covered for requested services
• Submit authorizations for approval/denial, along with uploading/faxing clinical documents for clinical review
• Insurance/authorization verification/determination with commerical/medicaid and medicare plans
• Ensure all data elements pertaining to the requested services are entered in Revenue Cycle (EPIC)
• Working Remotely
PRIMED-HILL PHYSICIANS MEDICAL GROUP-SACRAMENTO, CA Outpatient Outreach Coordinator/ Patient Navigator/Authorization Rep December 2013 – April 2018
April 2018 – Present
• Working remotely processing authorizations and special projects
• Place calls to members following closure from complex case management at specific intervals to check status.
AND
01/08/14
• Daily review and monitoring of hospital discharges.
• Assign cases to WH team as identified on hospital proxy list.
• Maintains Welcome Home log to alert for WHC totals.
• Oversees and reconciles all acute transitions of care.
• Receive and process Intensive Home Medical Management (IHMM) referrals.
• Manages a CM queue to monitor IHMM cases for updating and attach IHMM progress notes to AE CM case.
• Accesses clinical records in hospital EHR to provider for clinical staff review
• Monitor Transplant cases that do not require complex CM services
• Monitors SNP Inpatient and discharge stats, maintains SNP logs.
• Maintains Care Coordination SharePoint resource binder, SNP IDCT, VCT IDCT and SNP spreadsheets.
• Prepares SNP meeting packets, gathers clinical records for IDCT weekly meeting.
• Participates in IDCT rounds.
• Updates AE SNP cases with IDCT recommendations.
• Process authorizations for IHMM, Transplant, Palliative and others following department workflows or as directed by nursing staff.
• Place outbound calls to members from risk reports to engage for care coordination team.
• Complete authorization request in accordance with the operational procedures
• Research and troubleshoot complex authorization
• Enter the authorization into the system using the correct ICD 10 and procedural codes
• Answer phones that are in the queue and monitor customer service request activities
• Assist member with locating providers
• Route appropriate calls to Nurses, CM, CR Nurses, Supervisors/Managers
• Assure Confidentiality of calls, documents and paperwork
• Receive calls from CS Reps, Nurses, CR, CM, Supervisors/Managers and other employees
• Maintain a list of Medical Providers who accept or do not accept the health plan
• Fax and/or scan authorizations request and/or clinical notes
• Ability to respect and maintain confidentiality and HIPAA guidelines
• Working with Cerner and EPIC for medical records PACIFIC STAFFING (Temporary Staffing)-SACRAMENTO, CA July 2013 - September 2013
• Picked up consents/Medicare letters @ Nursing Stations
• Made copies/scanned consents
• Breakdown patient charts
• Verification of insurance
• Created Inpatient Rehab packets
• Pre-admitted patients to Inpatient Rehab
• Authorizations
WALTON PEDIATRICS –Sacramento, CA
Referral Coordinator
March 2013 – June 2013
• Completed authorizations/referrals for specialty services via internet/referral forms or phone
• Completed direct referrals for Molina/Medi-Cal/Hill Physicians
• Looking up patients in the IMS system
• Calling and scheduling specialist appointments for patients and call to inform patients of their appointments AND
01/08/14
CORAM HEALTHCARE (subsidiary of Apria Healthcare)-Rancho Cordova, CA CUSTOMER SERVICE SPECIALIST IV
Insurance Verification Specialist
June 2012 to October 2012 (Temporary)
• Entering insurance information into a Salesforce (RPM2) patient entry information system
• Verification of insurance via phone/internet for Home Infusion Therapy using systems (Emdeon (WebMD) eligibility system)
• Noridian administrative services (HCPCS coding), (PDAC Medicare pricing, data analysis & coding),
• ICD-9 coding. Com (diagnosis coding website)
• NPPES (NPI registry search), UPIN/NPI ECARE online, CARECENTRIX portal, Medicaid websites, LabCorp Insurance list, Payor Admissions quick reference sheets (for major insurance companies), contracts insurance billing grids and using the Kea (CSARS/Legacy system for local rule entry) NEWTON MEDICAL CENTER - COVINGTON, GA
INPATIENT INSURANCE COORDINATOR
April 2004 to April 2012
• Inpatient/Observation insurance verification, pre-certification via Internet/phone - successfully resolved/assisted with patient insurance questions (co pays, deductibles, coins & self-pay patients)
• Resolved and completed emails from utilization review department
• Utilize EMR for (doctor notes, medical records etc.)
• Knowledge of ICD-9/CPT codes, complete MEDICAID ID numbers for newborn's, substitute jobs with Financial Counselor (cash handling, visiting patient rooms to collect co pays/deductibles/coins & self pays),
• Communicated with clinical staff, business office & managers,
• Scheduled basic radiology test and scanned into blue-chip
• Registered patients (outpatient, emergency room, women's diagnostic departments, pre-certification inpatient/outpatient test, verified & updated all demographic information and scanned insurance docs/pre- certification info/physician orders
PRIORITY PRIMARY CARE – LAWRENCEVILLE, GA
FRONT OFFICE LEAD
June 2002 to December 2003
• Check in/out patients, scheduled appointments
• Supervised front desk staff of (4)-four
• Collected copays/deductibles/coinsurance
• Open/closed office
• Reconciled end of night charges, bank deposits
• Completed medical records for (patients, insurance companies, specialist offices)
• Verified & updated demographic information and insurance
• Created patient charts
• Order supplies
• Called patients with negative test results and called in prescriptions
• Performed additional administrative/clerical duties assigned
• Completed referrals/authorizations
ALAN B MILLER, M.D – CHAMBLEE, GA
MEDICAL FRONT OFFICE RECEPTIONIST
AND
01/08/14
October 2000 to June 2002
• Check in/out, collected (copays, deductibles, open balances)
• Scheduled/confirmed patient appointments
• Insurance verifications
• Medical Records
• Patient referrals/authorizations
• Ordered supplies
• Posted payments
• Performed additional assigned administrative/clerical duties EDUCATION
TROY UNIVERSITY ONLINE Pursing BS in Human Services TROY, AL
COSUMNES RIVER COLLEGE Pursuing AS in Human Services SACRAMENTO, CA 95823
DEKALB TECHNICAL COLLEGE Certificate Accounting
COVINGTON, GA
NATIONAL EDUCATION CENTER 1992 Diploma
PHILADELPHIA, PA, USA
VOLUNTEER SERVICES
Drove Church Van, Greeter and Community Services/Food Bank assistant at Capitol City SDA Church and serve at Loaves & Fishes in Sacramento, CA.
REFERENCES
AVAILABLE UPON REQUEST
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