Project Manager & Prior Authorization Specialist
Resume:
PROFESSIONAL SUMMARY:
Innovative, results oriented project manager with over ten years of experience and a passion for building relationships and exceeding client and management expectations. Possessing fully developed communication and organization skills with attention to detail and the ability to plan implement and manage multiple projects simultaneously within inflexible time frames, as well as the ability to deal with priority changes. Successfully initiated and managed projects in the areas of accounting, insurance, customer care, operations, and numerous project request. Strong skills in team building, communication, as well as inter-department and executive client relations and account management. A demonstrated ability to effectively manage projects through their life-cycle and, upon completion, can achieve meaningful and measurable results.
EXPERIENCE:
Prior Authorization Specialist (Remote)
GI Alliance, March 2022 - Present
- Obtain all requests for precertification and prior authorization from
insurance companies for appointments, scheduled tests, and procedures.
- Contact insurance companies to obtain precertification and record data on forms.
- Communicate patient financial information with appropriate office and billing personnel.
- Document required information in the practice management system.
- Verify waivers have been signed as needed for tests and procedures prior to the date of service.
- Communicate with staff on any adjustments to precertification.
- Perform light data entry and other related office duties.
- Reviewing all insurance medical policies
Collections Representative II 12/09/2019-03/2022 Financial Concierge Advisor AIS Healthcare
Responsible for collecting, reviewing, and completing applicable care transition documents. Participates with data collection required.
Obtain all requests for precertification and prior authorization from
insurance companies for appointments, scheduled tests, and procedures.
Actively listens and probes callers in a professional and timely manner for billing questions.
Resolving customer concerns as the first line contact resolving claim resolutions.
Thoroughly documents customers' comments/information and forwards required information to the appropriate staff.
12/2018-12/2019 Patient Registration Coordinator Option Care Inf. Services
Support Irving, TX branch in the areas of nursing, pharmacy, warehouse, clinical support, and sales by assisting with the authorization, insurance verification and medical claims process.
Interacts with external service providers and the Option Care Commercial Team to transition new patients onto service with Option Care.
Coordinates the onboarding of referrals between different functional areas within Option Care including Pharmacy and Nursing. Warehouse and Revenue C Clients.
Proactively maintains and grows relationship with referral sources and serves as a key point of contact and presentative of Option Care. Attend meeting with key staff on accounts as needed.
Communication frequently with the commercial team to provide updates on patient referral status and resolve related issues.
Responsible for collecting, reviewing and completing applicable care transition documents. Participates with data collection required.
09/2014-12/2018: Forms Procurement Specialist Coram/CVS Infusion Services
Dallas, TX
Support Dallas, TX branch in the areas of nursing, pharmacy, warehouse, clinical support, and sales by assisting with the authorization, insurance verification and medical claims process.
Coordinate with the Insurance Verification Team to ensure all patient information has been collected and documented on the appropriate forms.
Create, generate and distribute statements of medical necessity for patients and obtains signatures from physicians for claims submissions.
Track missing patient forms and documents missing forms via computer and manual logs.
Confirm patient medical claims have been set up and paid correctly in computer system.
Develop/manage report matrix
11/2013-01/2014: QA/Billing Representative Medix Staffing Solutions, INC Amerisource Bergen
Frisco, TX
09/2011-07/2013 Reimbursement Representative Kforce/Genentech
Scottsdale, AZ
09/2010-07/2011 Patient Access Services (PAS) Representative BayCare Health System
Tampa, FL
11/2011-04/2010 Customer Service Representative Ceridian (COBRA)
St. Petersburg, FL
05/2007-11/2008 Authorization Representative Magellan Healthcare
Maryland Heights, MO
Responsible for all on-going activities related to the maintenance of and adherence to systems, processes, policies and procedures for all quality assurance activities related to program services, billing, and compliance.
Actively listens and probes callers in a professionally and timely manner to determine purpose of the calls.
Researches and articulately communicates information regarding member eligibility, benefits, claim status, and authorization inquiries to callers while maintaining confidentiality.
Resolves customer administrative concerns as the first line of contact - this may include claim resolutions and other expressions of dissatisfaction.
Assist efforts to continuously improve by assuming responsibility for identifying and bringing to the attention of responsible entities operations problems and/or inefficiencies.
Assist in the mentoring and training of new staff.
Assume full responsibility for self-development and career progression; proactively seek and participate in ongoing trainings (formal and informal).
Demonstrate flexibility in areas such as job duties and schedule in order to aid in better serving members and help organizations achieve its business and operational goals.
Educates providers on how to submit claims and when/where to submit a treatment plan.
Identifies and responds to Crisis calls and continues assistance with the Clinician until the call has been resolved.
Informs providers and members on company’s appeal process.
Lead or participate in activities as requested that help improve Care Center performance, excellence and culture.
Links or makes routine referrals and triage decisions not requiring clinical judgment.
Performs necessary follow-up tasks to ensure member or provider's needs are completely met.
Responsible for updating self on ever changing information to ensure accuracy when dealing with members and providers.
Support team members and participate in team activities to help build a high-performance team.
Thoroughly documents customers' comments/information and forwards required information to the appropriate staff.
Maintained Medical Records, and HIPPA compliance.
SKILLS:
- Communication Skills
- Time Management
- Critical Thinking
- Excellent Customer Service
- Adobe DC Pro
- EPIC
- Microsoft Excel
- Call Center Operating
- Data Entry
- Customer Relations
- Insurance Procedures
- Billing Procedures
- Benefits Verifications
- ICD-10
- Medical Terminology
- Research
- Analysis Skills
- Data Analysis Skills
- Microsoft Word
- Insurance Verification
- IV Infusion
- Microsoft Office
- Computer Skills
- Gastroenterology
- ICD Coding
- CPT Coding
- Organizational Skills
- Documentation Review
- Time Management
- Patient Care
- Communication Skills
- Customer Support
- Medical Collection
- Intake
- Writing Skills
- Medical Billing
- Medical Coding
- Medical Records
- Medical Office Experience
- EMR Systems
- Revenue Cycle Management
- Medical Documentation
- Cardiology
- Diagnostic Radiology
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