Authorization Representative Verification Specialist

KEVIN ARMOUR Mobile: 412-***-**** • ************@*****.*** • 7100 Beatty Dr S305, Irwin, PA 15642

PROFILE

●Experienced user of Microsoft Applications to include; Access, Excel, Word, Outlook, Skype, and PowerPoint.

●Benefit Administrator for many Fortune 500 companies like Oracle, Google, etc.

●Active participant in operational compliance and performance improvement initiative and application improvements programs.

●Extensive experience in streamlining systems and processes for communication and processing.

●Combined 10 years of prescription billing experience and claim interpretation providing assistance will full spectrum of benefits, Copay assistance, and patient access programs.

●Extensive experience in recognizing and reporting adverse events in compliance with regulatory guidelines

●Currently obtaining my RN license to be able to expand upon clinical compliance.

●Average Fluency in speaking and understanding Spanish.

●Extensive experience gathering required clinical information and submitting for Prior Authorizations within required timeframes.

●5-6 combined years of claims processing both NCPDP and non-NCPDP claims.

●Extensive experience in the review of claims and their approval or denial determinations or to ensure coverage on the billing side.

●Experienced in reviewing Prior Authorization criteria and determining if codes and documentation comply with medical necessity criteria.

●Extensive experience in B verses D Medicare Coverage determinations.

●Experienced in the use of fee schedules and formularies, to calculate contract rates and pricing.

●Experienced managing and supporting the needs of a team in the presence and absence of the supervisor.

●Extensive medical terminology, ICD-10, and procedure coding knowledge.

●Excellent organizational skills.

●Excellent skills obtained through 20 years of healthcare experience, to enable me to do chart reviews and audits and doing clinical reviews and care planning.

●Full understanding and capable of monitoring full outreach openings and disclosures to comply with both Medicare and Medicaid Guidelines.

●Very knowledgeable in specialty, infusion, and retail meds and their use and prescribing guidelines

●Experienced in handling; escalations, appeals & grievances, adverse events, fraud & abuse.

●Ability to multi-task and prioritize work to ensure timeliness and quality measures are all met.

●Willingness to delegate work if running behind along with taking on extra work to get others caught up.

●A self-starter capable of working with minimal assistance and supervision and perfectly comfortable learning virtually and working remotely.

PROFESSIONAL EXPERIENCE

Cigna Accredo-An Express Scripts Company May 2020 - May 2022

Pittsburgh, PA

Eligibility Representative / Senior Prescription Benefit Specialist

●Review enrollment/application forms for patient assistance, following quality check to ensure proper use of HCPCS, CPT, ICD-9 and ICD-10 coding, accurate diagnosis description, and check to ensure patient and provider signatures are on file, and that prescriptions are written correctly.

●Adverse events reporting for compliance.

●Interpretation of coverage to transition to retail mail order and offer copay assistance while educating patients on coverage of medication.

●Utilize RxHome, ESD,and CoverMyMeds to review applications, request/review prior authorizations, and document plan benefits.

●Utilize understanding of commercial and government payers to obtain current eligibility and benefits along with confirming authorization requirements and approval/appeals.

●Process Dummy claims to determine; coverage, cost over-ride needs, Copay assistance or PAP needs, and Prior-Authorization Approval.

●Obtain, report, and follow-up on all patient and provider complaints pertaining to medication, quality, delivery, coverage, and symptoms.

●Process medical and pharmacy claims.

●Obtain Prior-Authorizations and Renewals by communicating with Health Care Providers and Insurance Companies.

●Proficiently use Microsoft Excel, Outlook and Word to make documents and to streamline processes for accuracy and efficiency.

●Utilize Templates to ensure accuracy and consistency in chart notes.

●Train others in the Authorization process and with customer service etiquette.

●Monitor emails & reports to assign tasks accordingly and to route emails to the correct reps.

●Adherence to timelines for both patient needs and compliance.

●Adhere to HIPAA guidelines in record handling along with proper credentialing before discussing patient information.

●Follow IVR to obtain patient insurance plan information.

●Develop a full understanding of Rare Disease drugs.

●Enter all clinical information pertaining to applicant.

●Validate provider and site credentials and contact information to ensure accuracy to avoid HIPAA breaches and compliance with the prescriber.

●Review prescriptions for correctness and entered them into the system to schedule shipment.

●Monitor Accounts Receivable to ensure invoices with payment issues are resolved to ensure timely filing.

●Lead a Team of 5, training and assisting in working accounts receivable CODS to minimize write offs of debt.

Talent Staffing Services - Highmark August 2020 - December 2020

Pittsburgh, PA

Intake Coordinator

●Pull incoming Prior Authorization requests.

●Determine which plans PAs are associated with based of its UMI, patient name, and DOB

●Review clinical information and admitting information to determine urgency.

●Ensure completion of PA documents.

●Piece together new authorization information with existing cases or determine if a need to build new case.

●Adhere to compliance measures for PA turnaround times.

●Triage approximately 15 prior authorizations an hour.

●Review using coverage guidelines, diagnosis codes, and procedure codes to determine coverage and exceptions based off of medical necessity.

●Process working under clinical nurse.

●Send OBF to providers and case management for cases missing information, interrupted, or faxed to the wrong plan.

Lash Group AmerisourceBergen August 2019 - May 2020

Pittsburgh, PA

Benefit Verification Specialist

●Reviewed enrollment/application forms for patient assistance, following quality check to ensure proper use of HCPCS, CPT, ICD-9 and ICD-10 coding, accurate diagnosis description, and check to ensure patient and provider signatures are on file, and that prescriptions are written correctly.

●Utilize Fusion and PeopleSafe to create BVs, PAPs, and Prior-Authorization cases along with Missing Information Cases.

●Communicating any adverse events and reporting them to manufactures.

●Process documents for grant and assistance consideration.

●Utilized understanding of commercial and government payers to obtain current eligibility and benefits along with confirming authorization requirements and approval/appeal process.

●Performed income verification using Equifax.

●Validated financial eligibility using Federal Tax Returns, SSI Statements, or presented and verified income on application.

●Review and determine economic hardship consideration from signed letters from patients.

●Proficiently use Microsoft Excel, Outlook and Word to make documents and to streamline processes for accuracy and efficiency.

●Worked with new hired shadowing and training in the customer support and eligibility verification process.

●Utilized Blurb tools to properly comply with client expectations.

●Adhered to HIPAA guidelines in record handling along with proper credentialing before discussing patient information.

●Followed IVR to obtain patient insurance plan information.

●Developed a full understanding of Oncology, Rheumatology, Cardiology, and Hematology Drugs and coverage criteria.

●Entered all clinical information pertaining to applicant.

●Validate provider and site credentials and contact information to ensure accuracy to avoid HIPAA breaches and compliance with the prescriber.

●Calculate patient accounts receivable financial responsibility based off of their Adjusted Gross Income and their benefit structure.

●Reviewed prescriptions for correctness and entered them into the system to schedule shipping.

●Review benefits, income, residency, and provider information to determine whether to approve or deny patient for assistance.

A-Line Staffing – CVS-Pharmacy January 2019 - August 2019

Pittsburgh, PA

Benefit Verification Specialist

●Reviewed enrollment forms following quality check to ensure proper use of HCPCS, CPT, ICD-9 and ICD-10 coding, accurate diagnosis description, and check to ensure patient and provider information is correct.

●Confirmed site of service for Infusion patients and that all supplies were available and worked to coordinate nursing if needed.

●Insured that correct policy information, bill groups, bin numbers, group numbers, and pcn numbers are entered to enable the claims to process.

●Used SPARCS and HBS for documentation and processing claims for the specialty drugs to move onto the package and ship stage.

●Obtained prior authorizations for plans that required it for payments.

●Connected patients with financial assistance through manufacturer copay cards and assistance programs.

●Documenting Adverse events.

●Utilized understanding of commercial and government payers to obtain current eligibility and benefits along with confirming authorization requirements and approval/appeal process.

●Proficiently use Microsoft Excel, Outlook and Word to make documents and to streamline processes for accuracy and efficiency.

●Adhered to HIPAA guidelines in record handling along with proper credentialing before discussing patient information.

●Followed IVR to obtain patients’ Major Medical benefits for infused drugs.

Spectraforce Technologies - Lash Group September 2018 - January 2019

Pittsburgh, PA

Benefit Verification Specialist

●Reviewed enrollment forms following quality check to ensure proper use of HCPCS, CPT, ICD-9 and ICD-10 coding, accurate diagnosis description, and check to ensure patient and provider signatures are on file.

●Utilize Fusion to create BV and Prior-Authorization cases along with Missing Information Cases.

●Utilized understanding of commercial and government payers to obtain current eligibility and benefits along with confirming authorization requirements and approval/appeal process.

●Proficiently use Microsoft Excel, Outlook and Word to make documents and to streamline processes for accuracy and efficiency.

●Utilized Blurb tools to properly comply with client expectations.

●Adhered to HIPAA guidelines in record handling along with proper credentialing before discussing patient information.

●Followed IVR to obtain patient insurance plan information.

●Reported adverse events and submitted to manufacturer.

●Developed a full understanding of Oncology and Rheumatology Drugs and coverage criteria.

UPS November 2017 - January 2018 Advent Global

May 2018 – September 2018

Pittsburgh, PA

Dispatch/Feeder and Package Handler

●Monitored scheduled vs actual package arrival times and made route adjustments as needed to ensure on time deliveries.

●Assigned trailers to contractors and ensured the destination and route were confirmed.

●Maintained log of available loaded and empty trailers to assign.

●Maintained log of locked out trailers needed necessary repair.

●Confirmed packages in trailers and wrote out seal slips to hand driver when route was ready and instructed drivers to call out to security to make sure trailers were sealed before leaving.

●Sort packages based upon slick codes and zip codes, to make sure packages are routed through facility correctly and loaded onto trailers to be in transit.

●Follow all safe lifting and HAZMAT safety guidelines.

Unemployed January 2018 - May 2018

Stay at home parent of a newborn

Sheetz June 2017 – November 2017

Pittsburgh, PA

Sales Associate

●Provided excellent customer service while up-selling on products.

●Prepared food and drinks.

●Performed all 3rd shift stocking and prep duties

Sterling Professionals- Mortgage Connect June 2017 – September 2017

Pittsburgh, PA

Closing Coordinator

●Placed outbound calls to borrowers to ensure they closed on the properties as scheduled with no problems.

●Reached out to borrowers for funds due for closing costs.

●Scanned and processed all mail, deeds, liens, etc then handed them to the closers.

Gateway Health Plan June 2015 – March 2017

Pittsburgh, PA

Customer Service Representative

●Receiving/placing inbound/outbound calls to adhere to Centers for Medicare Services’ guidelines and call volume quotas, while offering 5-star service.

●Reviewing and interpreting benefits and coverage.

●Perform electronic chart audits to ensure correct and timely documentations.

●Trained pharmacy staff in obtaining info for and documenting adverse events.

●Obtains clinical data needed for services as required.

●Schedule, validates patient demographic data and verify medical benefits.

●Processing, scheduling, and follow ups for appeals and grievances regarding coverage denials along with complaints about service providers.

●Correct all necessary data to ensure an accurate bill is submitted to patient and accounts receivable.

●Utilized extensive knowledge in Medicare and Medicaid benefits to professionally handle member service calls, ensuring compliance and member satisfaction while assisting with member inquiries, provider questions, and contracting inquiries.

●Identifies all patient financial responsibilities and collect any liabilities

●A lead with the pharmacy customer service call center responding to over-tides, edits, and employee/patient resolutions.

●Communicate the added benefits in selecting a Gateway Medicare Assured plan as opposed to the plans of our competitors and as soon as interest is expressed, transferring to enrollment.

INDEPENDENT CONSULTANT January 2013 – June 2015

Corporate Communications Specialist @ Brightside Academy

Pittsburgh, PA

●Followed up with employees and units to find out leave status.

●Filled out and mailed to employees, FMLA 381, 380-E, and 382 forms based upon eligibility and for FMLA status and physician request and release information.

●Managed retirement plans/pensions, health insurance, life insurance, and 401K plans.

●Track time frame for employee follow-up on receipt of FMLA paperwork.

●Monitor and maintain employee portal communications for benefits, employee recognition, and events.

Bio-Med Medical Equipment Tech @ CareFusion

Pittsburgh, PA

●Placing outbound calls to account holders and supply contractors, to ensure satisfaction of products and services.

●Maintain relationships with client hospitals in which accounts are maintained.

●Perform on site equipment calibrations and inspections.

●Maintain maintenance logs and calibration statistics to ensure accurate record keeping of infusion equipment.

Prior-Authorization, Billing & Rejections Handler @ Alixa-Rx

Pittsburgh, PA

●Performed the central billing and resolution responsibilities to ensure timely payment to pharmacy and proper facility/patient billing.

●Maintained financial spreadsheets utilized for tracking of defaulted accounts and debt collection.

●Obtained authorization for payers to enable payments to be processed.

●Monitored account payables and worked with entities to capture $30K to $40K daily, primarily through insurers.

Senior Prior Authorization Representative @ Accredo/Express Scripts

Pittsburgh, PA

●Established Contracts.

●Worked with contracted agencies to establish patient care.

●Identifies self-pay and complex liability calculations

●Verified coding to ensure proper coding and PID number in place to ensure timely payments of services and products rendered.

●Effectively coordinated, processed, and communicated with doctors, payers, case managers, nurses, and leads to obtain products and services in a timely fashion.

●Rendered exceptional customer service skills and professionalism in phone etiquette, while meeting the volume and deadline demands.

●Performed calls to patient obtaining service consent while reviewing with patient, their financial obligations and responsibility, along with the next steps in the treatment process.

Billing Specialist @ Chartwell Infusion Pharmacy

Pittsburgh, PA

●Established pricing and billed for products/services for providers not contracted.

●Worked one-on-one with discharge planners, case workers, and medical staff, to develop pharmaceutical sales through enhancing leads.

●Performed Insurance Verifications of all types.

●Called and scheduled the patient care and infusion needs with appropriate contracted agencies.

●Reviewed and addressed and customer concerns with various contractors.

Providence Healthcare Management December 2011 – January 2013

East Liverpool, OH

Director of Patient Support Services/ Human Resource Director

●Performed selection, scheduled screening, hired, and did orientation for multiple offices, while communicating with management to ensure needs met.

●Created and sent denial letters to applicants not selected.

●Proactively designed and implemented aggressive marketing and business development tactics.

●Completed performance evaluations providing constructive feedback and follow-up for improvement.

●Performed wage analysis to recover from a 15-year wage freeze and transition to Employer of Choice.

●Negotiated benefit packages with carriers and discussed benefits with employees.

●Managed benefits for employees retirement, FMLA leaves, and general health benefits.

●Implemented a monetary performance bonus incentive to reduce ward and penalize to promote team oriented and customer focused operations.

●Trained all new employees on policies, procedures, and daily corporate objectives.

●Managed the annual budgets of multiple facility divisions with an annual amount of $2.5M to $6M.

●Processed and submitted payroll after insuring accuracy.

●Created Virtual systems for training to cut training cost and to communicate benefits and changes in policies and procedures to 1000+ employees, efficiently.

●Managed the operations and compliance of multiple facilities and multiple departments.

●Utilized established knowledge in Human Resources and Labor Relations, to maintain compliance.

HCR ManorCare

May 2003 – December 2011

Erie, PA

Assistant Dietary Manager/Admissions Coordinator/Director of Employee Retention Team

●Functioned as a mentor for new employees to assist in the development of new hires.

●Payroll processing, new hire benefit enrollment.

●Performed electronic charting and quarterly audits on charts for dietary and care plan documentation to ensure accuracy.

●Managed recruiting/employee appreciation/retention budgets and insured funds were properly allocated to maximize ROI

●Recruited and organize a team of 30 hourly and 100 volunteers into a cohesive goal-oriented marketing and fundraising team.

●Efficiently and effectively organized health fairs, career fairs, and other marketing and recruiting events with minimal impact on budget.

●Successfully established client relationships, which enabled referral works to grow strong.

●Monitored dietary budgets for staffing, equipment, and food supplies.

●Performed ordering of food and supplies and scheduling for department.

●Monitored try production adherence and operational efficiencies.

EDUCATION

Bachelor of Science in Nursing (April 2024)

Penn State University, New Kensington, PA

Certificate of Nursing (RN) (May 2023)

Western Pennsylvania School of Nursing, Pittsburgh, PA

Bachelor of Science; Business Administration

Penn State University, Erie, PA

Pre-Med

University of Pittsburgh, Pittsburgh, PA

GROUPS & VOLUNTEER

Oracle Program Development & Improvement

Work with vendors to investigate flaws in applications and areas for improvement to tailor packages to the particular audience

Contact this candidate