Prior Authorization Customer Service
Resume:
SKILLS & QUALIFICATIONS
Anthem
Problem Solving
Reports (Pathological)
Siemens Medical Solutions (SMS)
Allscripts
COB’s
Training
ICD-10-CM
Coding - Healthcare Common Procedure Coding System (HCPCS)/CPT
Billing
Customer Service
Independent worker
Insurance Policy and Procedure
Medicaid Eligibility
Medicare Eligibility
Prior Authorization
Communication (written/verbal)
Computers - word processing, database, web exchange, and spreadsheets.
WORK EXPERIENCE
May 2017 – Current
Utilization Management Technician Centene Corp. Indianapolis, IN
Determines contract and benefit eligibility.
Conducts clinical screening, Process in/outpatient prior authorization request, responds to telephone and written inquiries from clients, providers and in-house departments.
Refers cases requiring clinical review to a Nurse reviewer.
Checks benefits for facility based treatment.
Generate and track in/out going correspondence, Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
07/2016- Current
Utilization Management Technician MDwise Inc. Indianapolis, IN
Coordinate, generate, and track both incoming and outgoing correspondence related to the member for services or prospective services.
Conduct screening/surveys for case management services and identify needs for care coordination, and implement selected interventions according to program guidelines for members.
Interact with members, providers, facilities, and other staff to implement program interventions and facilitate receipt of information and records into JIVA for prompt review and response by the clinical staff.
11/2014 – 07/2015
Health Information Management
Indiana Health Home Health
Indianapolis, IN
Reviewed Face to Face/485 encounter document recovery.
Completed patient charts.
Ran Medicare report for outstanding encounter dates of service.
Entered and obtained encounter information with strict follow up practices.
Retrieved data information update recordings in Cerner.
Received new Medicaid referrals from referral agencies for in-home patient care.
Verified insurance and provider information.
Billed Medicaid claims and obtained prior authorization.
10/2013-11/2014
Intake/Billing Coordinator Caregivers Home Health Inc., Indianapolis, IN
.
Enter inbound patient referrals
Enter faxed patient referrals
Post Payments insurance payments
Utilizing Allscripts billing system for daily referrals and billing
12/2011 – 11/2012
Intake Coordinator
Utility Regulatory Commission
Indianapolis, IN
Entered consumer complaints for utility companies for the State of Indiana.
Dated stamp correspondence, scan and attach information to complaints.
Emailed analyst assigned complaints.
Adhered to Indiana Codes for the (IURC) hearings.
01/2011 – 06/2011
Breast/Cervical Cancer Coordinator
Indiana Department of Health
Indianapolis, IN
Enrolled patients into the Breast and Cervical Cancer (BCCP) Program.
Maintained verbal correspondence with patients.
Retained data and program spreadsheets.
Reviewed pathological reports.
Entered claim information into system.
06/2010 – 10/2010
Billing Rep
Indiana Mentor Network
Indianapolis, IN
Conducted outgoing calls relative to Indiana Medicaid regarding medical claim denials focusing on Adult Foster Care.
Obtained Medicaid remittance advice.
Copied and saved to the Mentor company access drive.
Ran business unit reports by group home.
Processed claims for Adult Mental Health, specializing in Medicaid.
02/2009 – 01/2010
Billing Rep
DCL Medical Labs
Indianapolis, IN
Maintained verbal correspondence with managers of extended care facilities.
Re-processed weekly claims denials specializing in Medicare, Medicaid, and MROs with the focus on extended care facilities.
10/2007 – 07/2008
Patient Financial Services Rep
Anthem MedPro Personnel
Indianapolis, IN
Maintained financial obligations with Anthem Recipients for mail order prescriptions and delivery.
Obtained information for Anthem Recipients offering a clearer understanding of insurance COB’s in regards to guidelines of plan policies and benefit coverage.
02/2001 – 04/2006
Patient Financial Services Rep II
Wishard Health Services
Indianapolis, IN
Maintained verbal correspondence with physicians and staff
Processed over 200 claims weekly for Midtown Mental Health, specializing in Medicaid, Medicare, and Commercial Insurances.
EDUCATION
Kentucky State University
Frankfort, KY
B.A. – Public Administration
December 2005
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