Remote Prior Authorization & Billing Specialist

Page *

ADRIANA C. BURTON

662-***-**** ***************@*****.*** Sardis, MS 38666

PROFESSIONAL SUMMARY

Healthcare access and customer service professional with extensive remote experience in prior authorization, benefits verification, care management coordination, provider/member support, claims-related research, and patient care. Skilled in reviewing authorization requests, researching medical policies and coverage criteria, verifying insurance benefits and eligibility, tracking approvals/denials, supporting appeals, documenting case activity, and communicating status updates to providers, patients, payers, and internal teams. Certified in Medical Billing and Coding with strong knowledge of HIPAA, medical terminology, CRM/Salesforce systems, and high-volume call center operations.

CORE COMPETENCIES

Benefits Investigation & Verification Prior Authorization Denials & Appeals Insurance Eligibility & Coverage Case Management Coordination Patient & Provider Support Claims/Denial Research Reimbursement Support Medical Billing & Coding HIPAA Compliance Medical Terminology Retro-Authorizations Prescription Coordination Clinical Documentation CRM/Salesforce Inbound Call Center Operations Data Management Follow-Up & Escalation PROFESSIONAL EXPERIENCE

Med II Prior Authorization Representative CVS Pharmacy Remote, Atlanta, Georgia August 2024 - Current

• Review prior authorization requests for completeness, accuracy, and required supporting information before payer submission.

• Research medical policies and coverage criteria, assess insurance benefits, and determine eligibility requirements for requested services or medications.

• Submit prior authorization requests electronically and by phone; track pending, approved, and denied determinations through completion.

• Maintain detailed records of authorization activity and process denial appeals in accordance with established procedures and payer requirements.

• Communicate authorization status, missing information, and next steps to physicians, providers, members, and internal departments.

Patient Care Advocate Alorica Remote September 2023 - March 2024

• Supported patients experiencing medical-related stressors through timely outreach, crisis intervention, and coordination with the appropriate care team.

• Participated in interdisciplinary case discussions to review complex patient needs and support coordinated plans of action.

• Conducted post-discharge follow-up calls to assess recovery, identify concerns or barriers, and escalate issues requiring further intervention.

• Monitored changes in patient status and communicated concerns to the primary care team for prompt resolution and continued follow-up.

Benefits Verification Specialist Teleperformance Remote March 2022 - April 2023

• Responded to benefits and coverage inquiries from patients, healthcare providers, and insurance companies by phone and email.

• Supported insurance verification activities, researched denied claim trends, and identified coverage-related issues requiring additional review.

• Tracked pending benefit verifications, prepared status reports, and maintained accurate documentation of verification activity and outcomes.

• Provided timely follow-up on open benefit verification requests to support efficient resolution and continuity of service. Customer Service Representative Humana: Work From Home Remote December 2022 - January 2023

• Handled customer inquiries and billing/service concerns in a remote call center environment while maintaining professional, empathetic communication.

• Resolved complex issues by coordinating with other departments and documenting follow-up actions and outcomes.

• Provided accurate information, managed escalated concerns, and completed follow-up contacts to confirm resolution and customer understanding.

Mental Health Technician Crossroad-Panola Medical Hospital Batesville, Mississippi August 2020 - December 2022

• Monitored patient condition, safety, behavior, and progress while documenting treatments, medication administration, and clinical observations.

• Collaborated with social workers, psychiatrists, counselors, nurses, and other team members to coordinate patient care and treatment planning.

• Participated in multidisciplinary case reviews and communicated patient changes or concerns to appropriate clinical staff.

• Provided patient and family education while maintaining confidentiality, safety standards, and accurate clinical documentation. Page 2

Mental Health Technician Region IV Mental Health Services Batesville, Mississippi August 2018 - November 2022

• Supported patient care through continuous observation, safety monitoring, behavior management, and accurate documentation of patient progress.

• Collaborated with multidisciplinary healthcare professionals to coordinate care plans and address patient needs across services.

• Participated in team meetings to discuss patient progress, treatment needs, interventions, and changes requiring follow-up. Banker Wells Fargo Remote May 2021 - December 2021

• Managed customer account servicing, identity verification, documentation, and transaction processing with a strong focus on accuracy and confidentiality.

• Handled escalated calls using conflict-resolution skills, researched customer concerns, and documented actions taken to support timely resolution.

Provider Services Representative BroadPath Healthcare Remote, Arizona City, AZ February 2017 - December 2020

• Supported provider and customer inquiries in a remote healthcare service environment, investigating concerns and coordinating solutions across departments.

• Maintained high-volume call performance while meeting service-level, handle-time, and productivity expectations.

• Documented inquiry outcomes, provided accurate information, and followed through on unresolved issues to support a positive provider/customer experience.

Care Management Coordinator Molina Remote January 2016 - December 2018

• Coordinated patient care activities with multidisciplinary teams to ensure medical, behavioral, and transition-of-care needs were addressed.

• Maintained detailed case records including diagnoses, medications, treatments, progress, and changes in condition.

• Supported discharge planning and participated in interdisciplinary reviews of complex cases involving multiple stakeholders.

• Facilitated communication and follow-up across care team members to support continuity of care and timely intervention. Customer Service Representative Lincare Remote, Missoui, KS July 2015 - November 2018

• Resolved customer billing, ordering, and service inquiries while providing accurate information and timely follow-up.

• Coordinated complex issues with other departments, updated account information, and documented resolutions to maintain service continuity.

• Managed customer complaints professionally and identified solutions based on individual needs and available services. Customer Service Representative Kforce Global Solutions Remote, Missouri City, MO March 2014 - December 2016

• Managed a continuous flow of inbound calls while maintaining service-level, responsiveness, and productivity expectations.

• Updated customer records, scheduled appointments, responded to service requests, and provided primary support to internal and external customers.

• Resolved customer concerns efficiently through accurate information, active listening, documentation, and appropriate escalation. EDUCATION & CERTIFICATIONS

Certified Medical Billing And Coding Specialist 180 Career Center, Jackson, MS August 2024 Bachelor Business Of Science, Health Services Administration South University, Savannah, GA August 2019 Office Assistant Certification Received Finch Henry Job Corp, Batesville, MS 2012 High School Diploma North Panola High School, Sardis, Ms 2010 Certification: Certified Office Assistant

Contact this candidate