Customer Service Rep/ Prior Authorization
Resume:
Adreinne Parker
**************@*****.***
Objective
Poised to utilize patient care and clerical skills to provide quality health services to patients. Bringing extensive knowledge of a customer service environment with a compassionate nature to complement the position.
Skills
Patient Oriented and Dedicated work ethic
Strong computer/typing skills and 10 key by touch
Excellent oral and written communication skills
Strong interpersonal skills
Proficient Medical Terminology
Education
Brightwood College North, Houston, TX
Patient Care Tech, CNA,Phlebotomy (Honors graduate 3.5 GPA), Graduate (06/2015-06/10/2016)
Sanford Brown College, Houston, TX
Medical Assistant, (Honors Graduate 4.0 GPA), (08/2009-05/2010)
Madison Senior High School, Houston TX
Graduate- (Diploma), (08/1987-06/1991)
Experience
Cigna HealthSpring/(Remote)Precertification Rep
06/2017-06/2022
Performing extensive phone contact with providers and requesting additional information for review based on Prior Authorization requirement protocols where necessary
Communicates with physician offices to obtain clinical information and/or coordinate peer-to-per conversations
Adhering to the established criteria and timeframes for processing urgent authorization or referral requests
Performing concurrent and retrospective reviews in collaboration with Concurrent Review Nurses, Case Managers and Medical Social Workers regarding member authorizations and referrals within the scope of their role
Reviewing Authorization Requests for completeness appropriateness prior to forwarding to an assigned nurse
Ensuring that any changes made to the authorization request or
referral forms have been submitted directly from the requesting
provider via electronically or by fax
Documenting all amendments received from providers on the
Review and Resolve Provider Change Request Form in the designated electronic
systems within the established time frame
Researching member history for duplications and consideration
of authorization limits
Responding to providers regarding the authorization/referral
Status which impacts the authorization process
Collaborating with Supervisor, providers and Claims
Department Staff to resolve problematic Authorization issues
Code each diagnosis of service and procedures according to standards
Memorial Hermann Hospital/Clinical Decision Unit
Patient Care Technician, 06/2016-06/2017
•Assisted in the admission, discharge and transfer process
•Collaborated and consulted with RN and other members of the interdisciplinary team for best patient care
•Positioned residents for comfort and to prevent skin pressure problems and patient sitting
•Prepared patients rooms prior to arrivals, assist with adequate nutrition and fluid intake and output
•Acted as a receptionist to the unit by directing, assisting and communicating to the patients families, visitors and other department personnel
•Collect patient data and identify and report pertinent findings to the RN
•Performed Phlebotomy, Glucose Meter Readings, Vital Signs, 12 lead EKG for patient testing
•Floated between hospital departments to provide needed support
•Maximized patient flow by providing superior operation support, executed in working alongside
ER physicians and Registered Nurses
Develop and maintained patient care plans as assigned by a registered nurse.
Assisted with Lab tech, collected, examined and logged data for 80+urine samples on a daily basis
Operated, maintained, and sterilized lab equipment including microscopes, automated analyzers,
Centrifuges, rotators and incubators to ensure accurate and timely test results
Addison Group Staffing
Member Benefit Representative,10/2014-6/2015
Effectively and Efficiently answered inbound calls from members and providers to help answer questions and resolve issues regarding health care eligibility, claims, payments, authorizations for treatment and EOB’s
Ensured that the proper benefits are applied to each claim by using the appropriate process and procedures such as claims processing, grievance processing and appeals
Resolved in-depth inquiries in a methodical manner independently and with I teenage and external business partners to find the appropriate resolutions,inefficiencies and high level of quality
Served as interdepartmental Liaison for all Medicare Enrollment /Eligibility questions
Gathered insurance information and submitted to appropriate department
Communicated and follow-up with team members regarding outstanding issues or client service management tickets
Managed email correspondences and telephone calls by promptly responding or redirecting if necessary
Managed multiple work streams, project manage to ensure timely delivery on objectives, and handle a very fast-paced timeline-driven environment
Consistently assisted with activities to ensure membership’s continuity of care, review health assessments and those that need follow-up with Star Plus Waiver Medical Necessity Level of Care form
Reviewed billing system (CMS) to verify patient’s eligibility to receive medication and updating necessary information
Getix Health
Financial Advocate, 8/2011-10/2014
Provided excellent services to hospitals and physician groups in the area of billing, collection of charges, provide information regarding patient financial assistance opportunities
Verified patients eligibility and coverage with insurance
Assisted healthcare providers with management and collection of payments from patients hospital bill and insurance company by acting as a transparent extension of their business offices
Responsible for the validity on medical claims seeking payment
Responsible for reviewing claims thoroughly to make sure there is no missing or incomplete information
Maintained and limited duplicate patient accounts
Running statistics reports for management
Evacuated patients financial status and established appropriate payment plan
Examined patients insurance coverage and deductibles
Updated patients financial information to guarantee accuracy
Established relationships and maintains open communication with third party payor representatives in order to resolve claims issues
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