Authorization Specialist Referral

MONTRELLA GALBRETH

323-***-**** **********@*****.***

OBJECTIVE

To obtain employment with a company that offers a positive atmosphere where I can use my interpersonal customer service skills to resolve customer issues and foster a positive relationship between the customers and the company for the betterment of all involve

Skill Summary

Medical Terminology

ICD-9/ICD-10 /CPT codes

MS Word, Excel, Outlook

EPIC/Cerner Systems 2016

EMR (Electronic Medical Records

Acute and Ambulatory Care

Discharge Planning

SNF (Skilled Nursing Facility)

Insurance Billing/Coding

Inpatient-Outpatient Authorizations-DME

E-HealthCare Software

Medical/Medicare

QNXT

IPAs, referrals, and medical authorizations. medical insurance

Employment History

Kaiser Permanente Moreno Valley, Ca. May 2020 – to present

Vaccination Administrative Support

Verify and check in patients for vaccination, and assist filling out paperwork for patients as needed

Answer questions regarding the vaccination process

Support LVN and RN whenever possible

Direct patients to appropriate location on vaccination site

Assist in ordering, receiving, storing, and transporting vaccines in accordance with guidelines, and work within organization policies, procedures, and guidelines.

.Assist with infection and waste control, cleaning, and sanitization of vaccination pod areas.

IHSS (In home Supportive Services) Hawthorne, Ca January 2000- November 2020

Caregiver (IHSS Certified)

Assisting elderly and senior clients with daily living activities (ADL’S) cooking, light cleaning, transportation, bathing, Medication reminders, and walking.

Provided Companionship, Socialization, and a clean safe living environment

Experience in assisting with varies diagnoses (Dementia, Depression, and Alzheimer’s)

LACETA (Los Angeles Center for Ear, Nose and Throat) Los Angeles, Ca. April 2018 April 2019

Pending Authorization Specialist/Authorization Coordinator

Create new patient charts

Handle the fax system to find an upload authorization to the EMR

Familiarity with EMR systems (AdvancedMD)

Call IPAs and check portals to check approval status

Ability to be forward thinking and identify and remedy potential problems before they arise

Collabera Staffing Svc (Molina Healthcare) Long Beach, Ca. August 2016-Feberary 2017

Care Review Processor II (Outpatient/Inpatient)

Process correspondence, running eligibility checks on websites, reviewing face sheets, building authorizations, using encoder pro and QNXT

Verify member eligibility and benefits.

Determine diagnosis and treatment request using (ICD-9/ICD-10 and/or CPT/HCPC codes), to Determine COB status

Verify inpatient hospital census-admits and discharges.

Trained in authorizations in various business lines (MMOP, MMP,and Molina Marketplace (Commercial plan)

Contact physician offices per Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.

LifeCare Solutions (Durable Medical Equipment) Irvine, CA July 2014 to January 8,2015

Patient Service Associate

Assisted walk-in patients with the selection of equipment supplies, and services inputted all relevant information obtained from patient referral sources into the computer systems.

•Process orders by preparing all appropriate paperwork and responded to telephone inquiries and orders from referral sources.

•Coordinated the delivery, setup and pickup of equipment supplies and services with appropriate personnel and contact patients to inform them of any patient payment requirements, determination of best delivery method and instructions for receiving delivery.

LA Care Health Plan Los Angeles, CA February 2013 to December 2013

Authorization Technician

Verified eligibility and benefits for each referral.

Input all referrals into MHC/CSIIM computer system and generated hard copy.

Provided referral and authorization to external providers. Such as incontinence supplies and dialysis authorization.

Provided information required for denial letters to clerical staff for patients whose benefits don’t cover requested services.

UCLA Medical Group Los Angeles, CA February 2012 to January 2013

Utilization Management Referral Specialist

Receive and process referral authorization requests from providers for Audiology, Mental Health and Nutritionist/Dietician.

Ensure all Consultation and follow-ups procedures are met in a timely matter: to include Allergy Med, OBGYN Ultrasound, Eye Exams, Rehabilitation, Chiropractic, Acupuncture, and Urgent referrals.

Research health plan benefit and eligibility issues when needed.

Receive phone calls from providers regarding member’s referrals and or issues

Gather additional information for pending referrals and approved or forward to case management nurse for review.

Community Health Plan- Los Angeles County/La Care Alhambra, Ca. September 2011 to December 2012

Authorization Technician /Utilization Management Department

Supports the Inpatient and Outpatient Case Managers by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.

Collect information required by clinical staff to render decisions and, assist the Case Managers and Director of the Medical Management department in meeting regulatory timelines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent review, and prepares UM Activity and Weekly Compliance Reports.

In addition, train new Authorization Tech.

CARE 1st Health Plan Monterey Park, Ca. June 2007 to April 2011

UM Coordinator/ Inpatient/Outpatient Utilization Management Department

Responsible for providing data entry support, assisting the inpatient Case Mangers in meeting coordination of care in Acute or Skilled Nursing Facility.

Verify all admissions and discharges for designated hospital daily into authorization system

Communicate daily with on-site Case Management Nurses to assist with eligibility and benefits.

Coordination with Ancillary Services Providers, such as PCP follow up, Ambulance services for member, home health, DME physician offices, hospice, Health plan partners and facilities.

Make certain authorizations for Home Health and/or DME discharge are process in a timely manner for members as needed and fax to appropriate vender.

Opening of clinical cases with preliminary information, attaching faxes to clinical records entry of Clinical Service authorizations for medically necessary.

EDUCATION

2015 Long Beach City College Long Beach, Ca.

Intro to Business/Human Resources/ Leadership

2014 Long Beach City College Long Beach, Ca.

Marketing/Sales

2004 Long Beach City College Long Beach, Ca.

Certificate of medical terminology and medical billing

2003 Regional Occupational Program Long Beach, Ca.

Certificate of medical billing

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