Healthcare Prior Authorization & Operations Leader
Resume:
Dynamic healthcare professional with
nearly two decades of experience,
including leadership at Brave
Healthcare, HCA Rose Medical Center.
Proven expertise in prior authorization
and insurance verification, coupled
with exceptional communication skills.
Successfully optimized workflows,
enhancing patient access and
satisfaction. Committed to compliance
and delivering high-quality patient
care while effectively managing
diverse teams. Skilled in leading
healthcare facilities through periods of
significant change and improvement,
with hands-on experience in strategic
planning, staff development, and
operational management. Known for
strengths in enhancing patient care
quality, implementing cost-saving
measures without compromising service
delivery, and fostering interdisciplinary
collaboration. Demonstrated ability to
improve patient satisfaction scores and
streamline hospital processes for
better efficiency across various
departments.
Almost two decades of healthcare
experience
8+ years of leadership and
management
Epic charting
Athena charting
Sales Force Charting
Meditech charting
Intermountain Healthcare
Prior Authorization Specialist [REMOTE] Denver, CO 09/2023 to Current
Reviewed prior authorization requests to ensure accuracy and completeness of required information.
Provided customer service to patients and healthcare providers, answering questions related to prior authorization and insurance coverage.
Collaborated with internal departments to provide account status updates.
Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
Educated healthcare professionals on how to properly submit a request for pre-authorization.
Processed appeals in a timely manner as per policy guidelines.
Communicated authorization decisions, including approvals and denials, to healthcare providers and patients. Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
Informed applicants of other agencies providing useful or related assistance.
Assisted healthcare providers with appeals for denied authorizations, including gathering additional information and documentation.
Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal
communication skills.
Facilitated communication between providers, payers and health plans regarding prior authorization processes. Proofread documents carefully to check accuracy and completeness of all paperwork.
Conversed with people from different cultures daily, providing high level of respect and patience with each interaction.
Notified ordering providers of denied authorizations. Ashley
Bills
***********@******.***
Denver, Co 80249
Personal Summary
Skills
Experience
AB
Process improvement
Documentation accuracy
Patient scheduling
Performance assessments
Problem-solving abilities
Customer relations
EHR documentation
HIPAA compliance and practices
CMS Insurance
Prior authorization
Insurance verification
Medical necessity review
Patient education
Customer service
Excellent communication
Recordkeeping and data input
Physician order verification
Private insurance
Authorizations
Surgery scheduling
Patient referrals
Training skills
Referral coordination
Attention to detail
Workflow optimization
Data management
Team collaboration
Medical terminology
Appointment scheduling
Workflow management
Patient confidentiality compliance
Insurance information oversight
Time management abilities
Team leadership
Compliance adherence
Financial counseling
Problem solving
Updating charts
Call center operations
High School Diploma
Adams City High School
Commerce City, CO,
06/2002
Some College (No Degree)
University of Colorado Denver
Denver, CO
Brave Health
Patient Access Team Lead (Adolescents)[REMOTE] Denver, CO 04/2020 to 12/2023
Provide supervision of day-to-day operations for the Pediatric/Adolescent Team in a remote work environment for 14 direct reports, as well as administrative oversight for the clinicians.
Monitor incoming call queues in a virtual call center environment.
Answer a high volume of incoming calls from community referral sources, clinicians, and patients.
Approve incoming referrals for the care model, insurance verification, and prior authorization of services. Provide families with their patient financial responsibility, while explaining what their insurance plan will cover. Schedule patient mental health appointments for individual therapy and psychiatry using Athena and Salesforce. Assist patients in coordinating community resources. After 6 months as an intake coordinator, I was able to identify a need for a better process for pediatric and adolescent referrals, focusing on HEDIS patients.
Created new processes and workflows to improve metrics and patient retention.
Conducted family and patient onboarding, including consents and provider transitions.
Coordinated with hospital caseworkers to establish the appropriate level of care.
Developed a community resource network for patients who were not appropriate for the Brave Health model, or who did not have insurance plans with which we were in network. Prepared daily reports on registration activities, highlighting areas for improvement.
Collaborated with other departments within the organization to ensure seamless transition of patients through their healthcare journey.
Processed patient co-pays, deductibles, and other payments, ensuring accurate financial records.
Applied HIPAA privacy and security regulations while handling patient information.
Performed quality assurance checks on patient data entered into system.
Assisted in obtaining prior authorizations from insurance companies.
Verified documentation methodically to avoid critical errors impacting care delivery and payments for services. Organized timely and accurate referrals to help patients obtain health care services and access available resources. Participated in training sessions related to new software programs or changes in policies and procedures.
Conducted financial counseling for patients, explaining Education
Psychology payment options and assistance programs. Adhered to HIPAA guidelines when handling confidential patient information.
Rose Medical Center
Patient Access Team Lead Denver, CO 01/2018 to
10/2020
Primary supervisor for Outpatient Radiology, Main
Admissions, Day Surgery, and the Emergency Department. Staff and order supplies according to budget guidelines, department needs, and budget.
Create staff schedules, and ensure adequate coverage. Model AIDET guidelines in all interactions with the patient, and ensure staff are adhering to the patient experience expectations.
Promotes and demonstrates excellent customer service. Maintain QA statistics (including patient wait times, etc.). And report results to the Supervisor or Manager.
Oversee the daily activities of the registration area to ensure that department standards are met.
Providing ongoing education to the registration staff When appropriate, relieve staff members during employee sick time or vacation.
Secure all signatures necessary for treatments, the release of medical information, the assignment of insurance benefits, and payment of services from legally responsible patients.
Work closely and professionally with nursing and ancillary departments in an effort to maintain a teamwork approach. Excel in all functions performed by patient representatives in all registration areas.
Collect/request deposits and copays.
Assume on-call responsibilities to ensure adequate staffing, and problem-solving.
Register patients in the EHR (Meditech).
Assists in resolving patient concerns.
Act in the capacity of supervisor or manager in his or her absence, and inform the supervisor or manager of all issues upon his or her return.
Maintains the effectiveness of patient flow.
Obtained informed consent and payment documentation from patients and filed in system.
Managed patient registration activities including verifying insurance eligibility, collecting co-pays and deductibles and scheduling appointments.
Obtained necessary signatures for privacy laws and consent for treatment.
Assembled registration paperwork and placed identification bands on patient.
Developed and implemented policies and procedures related to patient access services.
Collaborated with other departments on projects as needed to ensure desired outcomes were met.
Monitored billing processes to ensure accuracy of information entered into system databases.
Monitored waiting areas to ensure a comfortable and safe environment for patients and visitors.
Reported liabilities and risk management concerns to supervisor for review.
Attends in-service presentations, and completes mandatory education, including, but not limited to, infection control, patient safety, quality improvements, MSDS, and OSHA standards.
Demonstrates knowledge of the occurrence reporting system and utilizes the system.
Explained policies, procedures and services to patients. Applied HIPAA privacy and security regulations while handling patient information.
Accessed programs and set up correct payment strategies based on patient means and needs.
Registered patients by completing face-to-face interviews to obtain demographic, insurance, and medical information. Performed quality assurance audits on various processes within the department.
Conducted financial counseling for patients, explaining payment options and assistance programs.
Conducted performance reviews for all direct reports. Compiled information from patients and caregivers or family members to identify care concerns.
Supported emergency department registration during peak times, ensuring rapid patient processing.
Communicated financial obligations to patients and collected fees at time of service.
National Jewish Health
Referral/Prior Authorization Coordinator Denver, CO 06/2017 to 12/2018
Using EMR and internet-based programs to verify and import insurance information into the practice management software and EMR.
Reviewing and processing all new referrals for the sleep clinic and diagnostic sleep testing.
Reviewing physician documentation to establish clinical need for insurance purposes.
Counsel patients on the process of obtaining prior authorization, and the costs of diagnostic testing as it pertains to them.
Submitting prior authorization requests online, by phone, and via fax.
Scheduling existing patients for follow-up appointments in our sleep clinic.
Communicating ongoing documentation needs to referring physicians in order to provide timely and appropriate care. Using Outlook to receive and send email communication and faxes.
Managing a multiline phone system and up to five clinical care programs on a daily basis.
Collaborated with providers to obtain missing information required for authorization submissions.
Communicated authorization decisions, including approvals and denials, to healthcare providers and patients. Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal
communication skills.
Followed up on pending prior authorization requests to ensure timely processing.
Clarified patient inquiries and questions to update patient account information in computer system.
CU Rocky Mountain OBGYN
Patient Care Coordinator Denver, CO 01/2017 to
06/2017
Answer a high volume of incoming calls.
Checked in patients using EPIC EHR
Schedule all OB recurring appointments according to the appropriate clinical schedule.
Schedule all gynecology procedures, including gynecology and obstetrics, at the hospital or surgical centers. Collect insurance information.
Insurance verification.
HIM management
Cash handling, co-pay collection, cost share collection. Prior authorizations for medication and in-office procedures. Provided emotional support and guidance to patients and their families.
Coordinated patient care services with the medical team to ensure quality and timely delivery of care.
Performed administrative duties such as filing paperwork, answering phones, and scheduling appointments.
Organized timely and accurate referrals to help patients obtain health care services and access available resources. National Jewish Health
Call Center Representative Denver, CO 03/2016 to 05/2017
Answer a high volume of incoming calls in a call center setting.
Accurately input patient demographics into the system. Complete intake questions while effectively explaining the tobacco cessation program and its benefits to the caller. Schedule an initial call with the counselor.
Provide new participants with the correct program details. Answer questions regarding Nicotine Replacement Therapy. Complete outgoing calls for new physician referrals to complete intake into the program.
Complete outgoing calls for scheduled phone appointments with the counselor.
Engaged actively with callers, confirming or clarifying information and diffusing anger.
Maintained strong call control and quickly worked through scripts to address problems.
Presented existing and prospective customers with valuable service or product information to aid in decision-making. Offered additional products or services to enhance customer experience.
Optimal Women's Health
Practice Manager Denver, CO 07/2014 to 07/2016
Worked side by side with Dr. Ginsburg to create and open her private practice when she departed from corporate
healthcare.
Migrated all preexisting patient charts from the previous practice for a seamless transition of care.
Scheduled all surgeries and deliveries with the hospitals and surgical centers.
Conducted all insurance verifications and prior
authorizations for care.
Addressed any denials.
Built work schedules and staff assignments, taking workload, space and equipment availability into consideration. Checked entire office and waiting areas regularly to provide clean and organized surroundings.
Ensured compliance with relevant state laws governing healthcare practices.
Reviewed monthly financial statements for accuracy and completeness before submitting them for audit purposes. Ordered supplies needed and kept tabs on inventory levels. Supported entire practice's staff, which boosted efficiency and improved overall process flow.
Motivated staff by offering direction and providing constructive feedback.
Managed vendor relationships for supplies and services related to the practice.
Created and maintained electronic record management (EMR) systems to store data and develop reports using ATHENA EHR. Complied with OSHA and HIPAA regulations.
Monitored compliance with HIPAA regulations concerning patient privacy rights.
Consulted with clinicians to develop business strategy. Assessed need for additional staff, equipment and services based on historical data and seasonal trends.
Aspen Medical Group
Patient Coordinator II Denver, CO 06/2015 to 03/2016 Manage a multi-line phone system.
Patient care coordination for a busy five-provider internal medicine practice.
Schedule New Patients.
Schedule Existing Patients.
Collect Co-Pays
Insurance verification.
Counsel patients on insurance coverage.
Triage calls for medical assistants.
Process, scan, and distribute incoming faxes.
Close front office collections at the end of each shift, and prepare the deposit for the Practice Manager.
Collaborated with clinical and administrative staff to meet patient needs.
Verified documentation methodically to avoid critical errors impacting care delivery and payments for services. Instructed patients on policies and required actions for different types of appointments and procedures.
Updated reference materials with Medicare, Medicaid and third-party payer requirements, guidelines, policies and list of accepted insurance plans.
Utilized hospital systems to update patient records, ensuring accuracy and completeness.
Managed patient check-in process, ensuring accurate data entry of personal and insurance information.
Registered patients by completing face-to-face interviews to obtain demographic, insurance, and medical information. Kept patient appointments on schedule by notifying providers of patients' arrival and reviewing service delivery compared to schedule.
Maintained confidentiality of patient information in compliance with HIPAA regulations.
Diversified Radiology of Colorado
Radiologist Assistant Lakewood, CO 01/2014 to 08/2014 Appropriately identify and prepare radiology scans and X-rays for reading.
Process and relay the interpretation of radiologists' findings to ordering physicians.
Answer the multi-line phone system.
Obtain prior scans and X-rays from the PACS system. Process after-hours trauma calls, and page the appropriate on-call radiologist.
Alliance of Therapy Specialists Inc.
Health Information Manager Greenwood Village, CO 03/2012 to 02/2014
Create and refine new therapist training.
Conduct Therapist Initial Training (including but not limited to: documentation, ATS policies and procedures, HIPAA, forms, timelines, contacts).
Quarterly Chart Audits.
Lead and maintain the Chart Audit Committee.
Review and complete all medical records requests.
Facilitate all documentation for AAC funding.
Management of the Early Intervention Database.
Tracking and updating therapists' documents.
Monitor and clear charts of new patients to be added into the normal Medical Records rotation.
Design, present, and refine new policies and procedures regarding documentation and medical records processes, including the intake and discharge processes.
File and maintain medical records from intake to discharge. Train staff: ongoing training on documentation, processes, policies, and procedures.
Monitor clinical staff training required by the Community Center Board.
Procure and maintain clinical testing supplies and screening supplies, monitor the progress of Clinical Fellows closely, and maintain constant contact.
Mentor/Coach Therapists (caseload, documentation, policy, and procedure)
Maintained communication and transparency with governing boards, department heads and medical staff.
Managed changes in integrated health care delivery systems and technological innovations while keeping focus on quality of care.
Oversaw third-party billing and payment collection. Analyzed and interpreted health information data to identify trends and areas for improvement.
Created, maintained and updated patient medical records in accordance with HIPAA regulations.
Established solid relations with leadership and staff by attending board meetings and coordinating
interdepartmental information exchanges.
Directed, supervised and evaluated medical, clerical or maintenance personnel.
Provided guidance on coding practices to ensure accurate documentation of services provided.
Educated staff on best practices related to the use of EHR systems and other health information technology tools. Identified opportunities for process improvements related to the storage, retrieval and maintenance of health information documents.
Coordinated the release of confidential patient information according to applicable laws and regulations.
Developed and enforced departmental policies and
procedures related to the management of health
information.
Rocky Mountain Cancer Centers
Patient Care Coordinator - Oncology/Infusion Coordinator Centennial, CO 09/2011 to 02/2012
Communicated with patients to ensure quality of care and develop care plans.
Processed patient intake information and updated medical records prior to treatment.
Instructed patients on policies and required actions for different types of appointments and procedures.
Maintained accurate records of all patient care activities using electronic health record systems.
Organized timely and accurate referrals to help patients obtain health care services and access available resources. Scheduled evaluations and procedures for patients. Collaborated with clinical and administrative staff to meet patient needs.
Obtained informed consent and payment documentation from patients and filed in system.
Counseled patients on potential financial liabilities and payment requirements.
Explained policies, procedures and services to patients. Received and routed care team messages and documents to appropriate staff.
Coordinated patient referrals to specialists and other healthcare services.
Coordinated with insurance companies to confirm patient coverage and process claims.
Assisted in creating a positive environment for patients, family members, and staff by providing excellent customer service.
Physiotherapy Associates
Patient Services Manager Centennial, CO 09/2010 to 09/2011
Provide everyday customer service to patients and visitors as part of a front office staff member of a busy physical therapy w/ a combined pediatric occupational therapy office for nine clinicians seeing an average of 75 patients daily Maintaining patient charts
Answering a multiline phone system
Upon arrival of patient, check into scheduling computer system, collect copays, check patient into electronic medical record
Upon check out, schedule future appointments, provide any print outs of receipts or schedules upon request
New Patients, verify all demographic information with patient, verify eligibility and benefits via internet or telephone with the insurance company
My specific dealings were with the pediatric side of the practice and getting insurance coverage for pediatric occupational therapy and pediatric physical therapy Dealing mostly with Kaiser patients but all commercial insurances at one time or another
The Children's Hospital
Patient Placement Specialist Aurora, CO 10/2006 to 11/2010
As a Patient Placement Specialist, I was part of an interdisciplinary team, which included an RN Case Manager, an RN House Supervisor, and the Hospitalist. I utilized EPIC EHR to register patients and monitor demographics. I utilized the Teletracking Bed Board to assist in the floor admission of patients from the ED, PACU, and direct admissions to the floors based on acuity, staffing, and bed availability.
Alphapage LLC
Call Center Dispatcher Denver, CO 01/2004 to 12/2006 In my position as a call center dispatcher in a high-volume medical call center, I answered a high volume of calls, properly monitored and executed patient calls according to account protocols, as well as handled any calls that required de-escalation. This position was very KPI/Metrics-driven and required exemplary customer service and teamwork skills.
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