RCM Prior Authorization & Accounts Receivable Specialist

PRANJALI TEMBHURNE

Healthcare RCM Specialist Prior Authorization Accounts Receivable

Pune, Maharashtra 411057 766-***-**** *****************@*****.*** PROFESSIONAL SUMMARY

US Healthcare RCM professional with 5+ years across Prior Authorization, Eligibility & Benefits Verification, and Accounts Receivable in Behavioral Health, Physician Billing, and Cardiovascular specialties. Skilled in end-to-end authorization workflows for cardiac catheterization, vein ablation, and loop recorder procedures — including CPT/ICD-10 validation, clinical documentation review, and payer follow-up. Proven ability to manage high-volume caseloads accurately while meeting strict turnaround-time requirements.

CORE COMPETENCIES

Prior Authorization • Eligibility & Benefits Verification • Cardiovascular Authorization • Cardiac Catheterization • Vein Ablation

• Loop Recorder Authorization • Accounts Receivable • Denial Management • Appeals & Reconsiderations • CPT & ICD-10 Validation • Clinical Documentation • Availity & NaviNet • Clearinghouse & EDI • No Surprises Act • IDR & Open Negotiations

• High-Volume Case Management

PROFESSIONAL EXPERIENCE

Prior Authorization Specialist — Access Healthcare Apr 2024 – Present

• Process prior authorization requests for cardiac catheterization, vein ablation, and loop recorder procedures via Availity, NaviNet, and payer portals, ensuring accurate, timely submission.

• Verify patient eligibility and benefits to confirm coverage and authorization requirements prior to scheduling, reducing risk of downstream claim denials.

• Review CPT/ICD-10 codes against plan-specific authorization criteria and clinical documentation to support medical necessity.

• Coordinate with provider offices, clinical teams, and insurance representatives to resolve missing documentation and prevent authorization delays.

• Handle urgent, high-volume caseloads while consistently meeting accuracy and turnaround-time standards. Accounts Receivable Specialist — Primera – Hyderabad Dec 2020 – Aug 2023

• Managed hospital and physician billing AR, following up on unpaid and outstanding claims to accelerate collections.

• Handled No Surprises Act out-of-network claims, preparing open negotiation letters (80% charge model) and coordinating the IDR process.

• Contacted payers regarding claim status, denials, and underpayments; conducted appeals and negotiations to recover underpaid claims.

AR Executive — Ascent Business Solutions – Nagpur 2019 – 2020

• Managed AR for General Physician and Behavioral Health services, covering electronic and paper claims.

• Reviewed unpaid, denied, and aged claims, submitting appeals and reconsiderations to resolve outstanding balances.

• Verified insurance eligibility and benefits prior to claim submission; investigated denials and payment discrepancies. EDUCATION

B.E., Computer Engineering: Madhukarrao Pandav College of Engineering, Nagpur University — 2019 Diploma, Computer Engineering: SSPP, MSBTE — 2016

TECHNICAL SKILLS

Healthcare & RCM Platforms: MedSuite, Epic, eCW, AdvancedMD, SAP, TriZetto, Optum Payer & Authorization Portals: Availity, NaviNet, and payer-specific authorization portals Other: MS Excel/Word/Outlook, Clearinghouse & EDI, CPT, ICD-10, Claims Processing, Medical Records Review LANGUAGES

English • Hindi • Marathi Typing Speed: 30 WPM

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