Prior Authorization Specialist
Resume:
CHARRIYSE WAITERS
PRIOR AUTHORIZATION SPECIALIST
205-***-**** Birmingham, Al 35235 *********@*****.*** SUMMARY
Highly organized and detail-oriented Prior Authorization Specialist with 20 years of experience in handling medical claims, obtaining prior authorizations, and navigating insurance requirements. Proficient in coordinating with healthcare providers, insurance companies, and patients to ensure timely approval of procedures and medications. Strong understanding of medical terminology, insurance guidelines, and HIPAA regulations. Known for accuracy, efficiency, and the ability to work independently in a remote setting. Seeking to contribute to a dynamic healthcare team while delivering high-quality administrative support. PROFESSIONAL SKILLS
● Prior Authorization Processing
● Insurance Verification
● Medical Claims Management
● Understanding of Medical Terminology
● HIPAA Compliance
● Electronic Health Record (EHR) Systems
● Customer Service in Healthcare
● Patient Communication and Education
● Insurance Appeals and Denial Management
● Time Management and Organization
● Strong Attention to Detail
● Data Entry and Documentation Accuracy
● Knowledge of CPT, ICD-10, and HCPCS Coding
● Proficiency in Microsoft Office Suite (Excel)
● Problem-Solving and Critical Thinking
● Remote Work Efficiency
● Team Collaboration and Coordination
● Multi-tasking in High-Volume Environments
WORK EXPERIENCE
Remote Medical Intake Specialist Dec 2023 – Present Imagine 360, Birmingham, AL
● Reviewed patient medical records and insurance policies to determine eligibility for prior authorizations.
● Collaborated with healthcare providers to ensure the submission of accurate clinical documentation.
● Processed authorization requests for medications, procedures, and diagnostic tests, ensuring compliance.
● Followed up on pending authorizations by contacting insurance companies and addressing issues.
● Resolved denied authorization claims by investigating causes and providing clinical information.
● Ensured HIPAA compliance and the secure handling of patient data throughout the authorization process. Conducted primary source verification, managed provider credentialing files, and ensured compliance with NCQA standards.
● Compiled monthly credentialing reports and participated in quality improvement initiatives. Remote Non-Clinical Intake Coordinator July 2015-present Innovative HIM Solutions LLC, Birmingham, Al
● Verified patient insurance benefits and eligibility for specific medical treatments and services.
● Facilitated communication between healthcare providers and insurance companies to expedite approvals.
● Entered prior authorization requests into electronic health record (EHR) systems while ensuring accuracy.
● Communicated authorization decisions to both providers and patients, ensuring clarity on any next steps.
● Tracked authorization statuses to ensure timely follow-up on delayed or pending requests.
● Provided exceptional customer service by answering patient and provider inquiries related to authorizations and insurance policies.
● Reviewed patient records, accurately applying ICD-10 and CPT codes to ancillary records.
● Identified and rectified missing documentation, ensuring compliance with federal coding guidelines.
● Managed claims submission to private insurers, Medicaid, and Medicare, achieving timely reimbursement.
● Maintained confidentiality of chart and billing records, adhering to HIPAA regulations.
● Conducted primary source verification, managed provider credentialing files, and ensured compliance with NCQA standards.
● Compiled monthly credentialing reports and participated in quality improvement initiatives. Admissions Coordinator and HIM Assistant November 2005 – June 2015 UAB Hospital, Birmingham, AL
● Review and verify patient information, insurance coverage, and medical codes to ensure accuracy.
● Adjudicate medical claims based on insurance policy terms, medical necessity, and regulatory guidelines.
● Validate diagnosis and procedure codes submitted on claims for accuracy.
● Investigate and resolve claim discrepancies, coding errors, and billing issues through communication.
● Analyze claim denials and appeals, identify root causes, and take corrective actions to resubmit or appeal.
● Maintain accurate records of claims processing activities, generate reports on claim status, payment trends, and denial rates, and document audit trails for compliance purposes. EDUCATION
DEGREE
Credentialing Specialist Certificate
American Association of Professional Coders, 2024
Certified Professional Coder (CPC)
American Association of Professional Coders, 2019
Master of Science in Health Service Administration Strayer University, Birmingham, AL, 2017
Bachelor of Science in Healthcare Administration
Columbia Southern University, Orange Beach, AL, 2014 Certificate in Cybersecurity
Jefferson State Community College, Birmingham, AL, 2022
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