Customer Service Prior Authorization
Resume:
Yesenia Lopez
Summary:
Customer Service Professional with excellent experience in the medical field in handling calls from providers, members, insurance, and doctors regarding members benefits, premiums, deductibles, explanation of benefits, billing, and claims.
15+ years in customer service and healthcare industry including 8 years with pharmaceutical companies.
Utilize internal systems to resolve customer needs such as appointments, prior authorizations, claims, invoices, eligibility, benefits, appeals, TARs.
Provide insurance coverage, verification details prior authorization statues, and alternate funding options for existing and newly launched products. Provide offices with current plan forms, portals, and websites for prior authorizations and appeal submissions.
Capable of working in a fast-paced environment, multitasking, and prioritizing
Computer proficient. Accurate data entry; typing Speed 50 Wpm
Knowledge of medical terminology, insurance claims, and intake for Pharmacy
Bilingual (Spanish and English) with excellent communication skills
Languages:
Bilingual Spanish (Fluent)
English
Education:
High School, South Mountain High School, June 1991
Professional Experience:
Customer Service/Member Services Representative
Optum Medical Group
February 2023 - Present
Answer approximately 60 to 80 inbound customer calls to address inquiries and concerns from members within set productivity guidelines.
Serve as the liaison between the patients and other department sites.
Assist new or potential members in the choice of preferred care providers and supply general information about the medical group.
Provide services to internal and external customers involving the exchange of complex and sensitive information while acting as patient advocate. (HIPPA Guidelines).
Page clinicians and assist Telehealth Nurses as necessary (e.g., arranging DME, transportation and HH).
Utilize internal systems to resolve customer needs such as appointments, prior authorizations, claims, invoices, eligibility, benefits, appeals, TARs.
Translate oral information into concise and accurate written documentation per guidelines.
Data enter PCP changes into the system and processes paperwork, as necessary.
Use, protect, and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Recognize financial, medical, and legal risks based on data collected during customer interactions and follows appropriate procedures.
Gap Reason: Home stay Mother, Looking for a Remote role.
Insurance Specialist I (ISI)
AbbVie
February 2022 – November 2022
Provide insurance coverage, verification details prior authorization statues, and alternate funding options for existing and newly launched products. Provide offices with current plan forms, portals, and websites for prior authorizations and appeal submissions.
Clearly communicate and educate customers on the results of the investigation,
Quickly learn and utilize all internal and external electronic tools, communicate/collaborate with payors and providers to investigate insurance coverage efficiently.
Identify potential Adverse Event situations for reporting to Pharmacovigilance ensuring AbbVie meets FDA regulations.
Understand and comply with all required training, including adherence to federal, state, and local pharmacy laws, HIPAA policies and guidelines, and the policies and procedures of AbbVie. Complete all required training and perform all functions in the position (i.e., Role certification, product, and disease overviews).
Case Manager
MassMutual
March 2020 - December 2021
Coordinate life insurance application submissions in accordance with department quality and efficiency standards.
Review all life insurance new business submissions, seeks out additional information or corrections to applications when necessary, and issues policies once in good order.
Insurance Verification Specialists/ Call Center
McKesson Pharmaceutical, Scottsdale, AZ
November 2017 – March 2020
Completed 20 cases daily working in case managed system.
Called insurance company to verify eligibility, medical and pharmacy benefits, and co-pay.
Initiated and verified prior authorization.
Provided information on ICD-9 and CPT codes if coved by insurance.
Contacted doctor’s office to provide information of patient insurance.
Benefits Verification Specialists/Call Center
CVS Specialty Pharmacy, Chandler, AZ
February 2017 – October 2017
Completed 20-30 cases per day.
Pre-verification of insurance for patients
Ensure that patients’ health care benefits cover required procedures.
Contact the patient’s insurance company to verify coverage levels and works with individuals to educate them on their benefits information.
Entering data in an accurate manner, updating patient benefit information in the organization’s insurance system, and verifying that existing information is accurate.
Initiate prior authorization and verify if procedures require prior authorization.
Eligibility Specialist (Contract)
Magellan Rx, Scottsdale, AZ
August 2016 – December 2016
Effectively supports Magellan. SBU program operations ensure that data is entered accurately and timely as required by contract service level agreements. Communicates with appropriate contacts on eligibility issues and questions.
Answers incoming calls on eligibility, program benefits, plan limitations and point-of-sale edits from providers.
Proficient use of enrolment and claims point of sale for research and problem resolution.
Assists in data collection and reporting. Completes bi-weekly check write production for provider payment in the accounts payable system, reporting all operational issues and assisting with system issues.
Assists with quality monitoring and provides constructive feedback. Reviews production reports, identifies issues, and recommends resolutions; continually seeks to improve processes and increase efficiencies.
Assists in data collection and reporting.
Customer Service Assistant / Provider Relations in Billing
Phoenix Health Plan, Phoenix, AZ
December 2015 – July 2016
Receiving incoming calls from provider office, participants and doctors regarding members’ benefits, advising of premiums, deductibles, and co-pay.
Provide claim status to provider office, check number, date it was paid, what line item was paid, and any discrepancies of billing.
Advised provider office if CPT codes require prior authorizations and looked up prior authorization if it was approved or denied.
Assist in processing medical claims.
Received payment for commercial insurance plan.
Assist members in understanding the Exclamation of benefits.
Receiving calls from insurance companies regards to denied or unpaid claims.
Patient Care Specialist
Philodox Rx, Tempe, AZ
February 2015 – November 2015
Managed 60-120 inbound calls daily.
General intake for mail-order pharmacy.
Processed prescription claims.
Collecting accurate demographic information from patients and entering data into the system
Verified insurance information and advised co-pay.
Customer Service Assistant
Catamaran Rx, Chandler, AZ
October 2012 – January 2015
Process claims to insurance companies.
Overriding claims for payment when available.
Taking mail order calls for Medicare and Medicaid members.
Advised members of refills available and provided benefits.
Giving Benefits and Eligibility information.
Customer Service Assistant
DHL Express, Tempe, AZ
January 2011 – September 2012
Provide customer satisfaction through effective communication.
Resolution of untimely delivery/tracking packages.
Communicate with shipping companies to research package delivery and find resolutions to customer needs.
Insurance Verification
Bank of America, Chandler, AZ
March 2007 – June 2009
Receiving incoming calls from customers regarding insurance claims check for repairs on damaged homes.
Verified and scanned all documents properly making sure each was filled out and signed appropriately.
Calling customer to verify information is accurate in the system.
Customer Service Representative
Pearson, Phoenix, AZ
May 2006 – January 2007
Receive incoming calls from beneficiaries and providers requesting benefits eligibility status.
Responsible for changing the necessary information in the system regarding pharmacy plans, providing details on the various plans available.
Assisting beneficiaries into Medicare Part D Enrolment.
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