Level Work Authorization Specialist
Resume:
Annie Douzable Hood
*****.*.****@*****.***
Objective: To obtain, a professional position that will utilize my education, skills, and leadership abilities. In addition, a position that will offer advancement and provide an opportunity to gain additional knowledge and expertise.
Skills Profile
Proficient in ARIS (INFINITT), Synapse, Microsoft Word, Excel, Power point, MediTech, Med ware, Emdeon, Nthrive, Optum compliance checking, Web FormImprint, CDImport, eClinicalWorks10, HPF, Webpay, PacsCube, LifeImage, Nuance PowerShare, Powerscribe, SCI Scheduling and EPIC.
Knowledgeable and experienced with using CPT and ICD-10 manuals for diagnostic and Procedural coding with ability to Interpret Insurance Explanation of Benefits for payment posting.
Ability to multitask in a fast-paced environment with proven success in negotiations, collections, and third-party payers.
Excellent switchboard operator with great ability to enter and verify patient demographic information to file, make copies, memos, fax and perform administrative tasks efficiently.
Superb knowledge and skills managing all major medical care web portals for insurance and claims submission.
Ability to instruct and manage one’s behavior
Excellent organizational, communication and interpersonal skills
Willingness to learn, acquire and apply new skills
2022- present Stamford Hospital Stamford, CT
Authorization Specialist
Review chart documentation to ensure patient meets medical policy guidelines
Prioritize incoming authorization requests according to urgency
Obtain authorization via payer website or by phone and follow up regularly on pending cases
Maintain individual payer files to include up to date requirements needed to successfully obtain authorizations
Initiate appeals for denied authorizations
Respond to clinic questions regarding payer medical policy guidelines
Confirm accuracy of CPT and ICD-10 diagnoses in the procedure order
Contact patients to discuss authorization status
Other duties as assigned
Knowledge of procedure authorization and its direct impact on the practice’s revenue cycle
Understanding of payer medical policy guidelines while utilizing these guidelines to manage authorizations effectively
Handles the verification of insurance benefits for customers
Contacts primary care physicians in regard to referrals
Regularly calls insurance companies to follow up upon authorization approvals or denials
Explores other payment options with customer when needed
Keeps sensitive customer and company information confidential
2020- 2022 Stamford Hospital Stamford, CT
Denial Specialist
The Clinical Denial Specialist performs advanced level work related to clinical denial management. The individual is responsible for managing claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned. The Clinical Denial Specialist conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is needed.
The Clinical Denial Specialist writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome. The incumbent will also handle audit-related / compliance responsibilities and other administrative duties as required.
This incumbent will actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle management. Additionally, the Clinical Denial Specialist anticipates and responds to a wide variety of issues/concerns. The incumbent works independently to plan, schedule, and organize activities that directly impact hospital and physician reimbursement and assists in creating and maintaining documentation of key processes. This role is key to securing reimbursement and minimizing organizational write offs.
Core Responsibilities:
Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
Independently write professional appeal letters.
Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as UW Health policies and procedures.
Submit retro-authorizations in accordance with payor requirements in response to authorization denials.
Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.
Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
Identify opportunities for process improvement and actively participate in process improvement initiatives.
Customer Service Standards:
Support co-workers and engage in positive interactions.
Communicate professionally and timely with internal and external customers.
Demonstrate friendliness by smiling and making eye contact when greeting all customers.
Provide helpful assistance in anticipating and responding to the needs of our customers.
Collaborate with customers in planning and decision making to result in optimal solutions.
Ability to stay calm under pressure and deal effectively with difficult people.
2021- 2022 Norwalk Hospital Norwalk, CT
Patient Care Technician I within the General Surgery Dept
Listening to patients’ concerns and reporting them to nurses or other colleagues.
Keep patient rooms tidy and sanitized
Assist patient with everyday needs (personal hygiene, using the restroom, grooming etc.)
Monitor vital signs (temperature, pulse etc.) or EKG signals and patient condition
Assist nursing staff in administering basic treatments
Perform basic nursing procedures (e.g., changing bandages)
Ensure rooms have adequate patient care supplies
Assist patients with issues or needs
Performs and assists patients with activities of daily living. In doing so, performs bathing, positioning, skin care, ambulating, toileting and assists with transportation.
Performs and records in patients’ charts, basic nursing care procedures such as collecting routine specimens, taking V.S., intake and outpatient and weight.
Assist with achieving nutritional needs by preparing patient for meals, deliver/remove trays, distribute water and feed patients.
Performs procedures and treatments such as EKGs, preps, applications, and monitoring of patient’s response to restraints.
Assists in transferring patients, beds and patient care equipment to other rooms adhering to necessary safety precautions.
Completes various errands as requested such as retrieving and delivering supplies, specimens, instruments, test results and so forth.
Provide appropriate emotional support
2016- 2020 Stamford Hospital Stamford, CT
Lead Imaging Service Librarian, Facilitator and Registrar
Ensures legal requests from law firms are handled appropriately and efficiently.
Manages clerical responsibilities including but not limited to faxing reports and covering the front desk.
Locates and reconciles studies for referring physicians as well as assisting physicians with securing and viewing images in the various technologies available.
Scans proper paperwork into the PacsCube and Meditech.
Copies images to disc or film from Pacs.
Upload images from DatCard into Synapse.
Assist with Telerad as a facilitator using Aris Infinitt, Intelerad Technologist Portal and Synapse to send images to physicians’ offsite to be read.
Inform the radiologists of the exams that need to be read and assign the images that need to be read to the appropriate radiologist.
Assist Authorization Dept. with the stat line as a liaison. Retrieve vital information from the doctor’s office regarding the patient and inform the modality technician regarding the patient’s status and arrival. Input the information of the patient on a spreadsheet and send it to the proper channels.
Make calls to Dr’s offices in regards of retrieving an order for the past or upcoming exam regarding billing purposes.
Schedules Stat patients for urgent upcoming exams.
VIR Scheduler for the radiology department and assist with Dr. Miller’s personal schedule for both consultations and follow-ups for upcoming procedures.
2014-2016 Piedmont Corporate Healthcare Atlanta, GA
PASU Financial Advocate
Assist with Medicaid and charity care application procedures, educating patients about their financial liabilities, and developing patient payment arrangements for said liabilities.
Screen patients for eligibility for other potential funding sources when a patient is not able to meet his or her liability related to his or her services.
Initiate financial assistance application and assess patients for Charity Care eligibility.
Work directly with medical representatives, nursing, ancillary departments, insurance carriers, and other external professionals to assist families in obtaining healthcare and financial services.
Perform cashiering functions when necessary.
Complete and/or attend mandatory training and education sessions within approved organizational guidelines and timeframes.
Obtain pre-certifications, authorizations, and referrals to ensure managed care compliance for necessary inpatient and out-patient appointments.
Fulfill notification requirements for inpatient admits.
Generate estimates for upcoming patient appointments via EPIC.
EPIC Super-user and trained new staff on EPIC and the different ways to navigate through the system.
Ensure all required data elements are collected and validated for account creation in the Revenue Cycle systems.
Obtain, enter, and update demographic and other financial and clinical information necessary for financial clearance of scheduled patients.
Obtaining and submitting clinical details to the appropriate insurance in obtaining pre-certification.
Work closely with Case Management in ensuring accounts are worked properly and any authorization or notification has been secured.
Very familiar with ICD 9, ICD 10, and CPT Codes.
2013-2014 Piedmont Corporate Healthcare Atlanta, GA
Inpatient Verification Representative (call center)
Efficient in self-pay process and determination of self-pay procedures.
Contact payer for verification of benefits for scheduled patients prior to service
Contacted payer for verification of benefits for all non-schedule patients with 24-hours post admit
Confirms authorization with payer prior to date of service for scheduled patients
Confirms authorization for non-schedule patients with 24-hours post admit
Performs notification functions upon patient admit for both scheduled and non-scheduled patients as appropriate
Interacts with Case Management regarding account authorization status as necessary
Requests authorization due diligence from referring physicians on non-authorized accounts as necessary
Promotes patient satisfaction; responds to inquiries or service complaints professionally using tact and diplomacy in resolving issues and communication with patients, physicians, practice area staff and management, and third-party payers; informs patient of role in process
Adheres to due diligence steps as defined in Insurance Verification Situation Response Guidelines and is able to choose the most appropriate scenario for situation at hand
Thoroughly documents all account activity in system as defined in the Insurance Verification Situation Response Guidelines
Manages timely verification, authorization and notification activities on an assigned populations of accounts
Meets productivity requirements as outlined in the performance expectations
Meets quality requirements as outlined in the performance expectations
Self-pay arrangements for indigent patients
developing patient payment arrangements for said liabilities
2012-2013 Piedmont Corporate Healthcare Atlanta, GA
Patient Financial Clearance Team Lead Rep II (call center)
Collected balances on patient’s account that are having future procedures.
Performed insurance verification and confirmed benefits eligibility.
Gathered patient’s demographic, financial data elements, and created a complete registered account for scheduled visits.
2010-2013 Piedmont Fayette Hospital Fayetteville, GA
Patient Access Representative II
Assisted patients during the onsite registration, admission, and arrival process for scheduled and unscheduled visits in both inpatient and outpatient settings.
Performed insurance verification for both “walk-in” visits and scheduled patients as necessary.
Serviced more than one facility such as the NICU, Women’s Center, Radiology, CV Imaging, a Sitter and the Main Registration area.
Acted as liaison and kept opened lines of communication among doctors, insurances and patients.
Trained incoming employees on current software and daily tasks to help register the patients efficiently.
Patient Pre-Registrar /Pre Service 2011-2012
Performed Preregistration for all patients including the Pregnant Mother’s to be, the patients were called and registered over the phone inputting all the vital information that is needed prior to appointment with the hospital staff.
Collected balances on patient’s account that were delinquent and on patient’s account that were having future procedures.
Education
Bachelor of Science in Psychology minored in Chemistry, The College of New Rochelle, New Rochelle, NY Dec 2002
Masters in Organizational and Behavioral Psychology, Walden University, (in progress / EGD: 2022)
Professional References upon request.
Contact this candidate