Prior Authorization Coordinator Resume Samples

Description :

1. Promoted the quality and cost effectiveness of medical care through strict adherence to all U.M.
2. Executed the principles of Prior Authorization to facilitate the right care at the right time in the right setting.
3. Communicated effectively and interact with the provider group and health plans Return phone calls to providers and follow up with requests in a timely fashion.
4. Processed request that are approved, denied or deferred and bring them to resolution.
5. Responsible for Deferred authorization maintenance, tracking and follow up.
6. Administered client and corporate guidelines to determine approval or denial of requested medications and/or devices.
7. Interacted with clinical program managers when necessary.

Experience

2-5 Years

Level

Executive

Education

Business Studies

Description :

1. Communicated with patients to obtain information required to process prescriptions, refills, access benefits and apply charges against co-pay cards, and build trusted and enduring customer relationships that yield loyalty.
2. Investigated and verified benefits for pharmacy and medical third party claims for assigned cases.
3. Communicated with financial assistance team of drug manufacturers to apply for and secure financial assistance for patient when assigned.
4. Obtained prior authorizations.
5. Initiated requests, follow up to provide additionally required information, track progress, and expedite responses from insurance carriers and other payers, and maintain contact with customers to keep them continuously informed.
6. Tracked, reported and escalated service issues arising from requests for authorizations, financial assistance or other issues that delay service.
7. Ensured patient access and to avoid delays that may interrupt therapy.

Experience

10+ Years

Level

Senior

Education

Bachelor Of Science

Description :

1. Processed referrals internal and external ( request from MD or Hospital) for injectable drugs in office use or self injections.
2. Filled out Insurance forms for several Insurance ( Blue Cross, Cigna, Medical, etc.).
3. Reviewed patients chart for labs, and test needed.
4. Documented all phone calls with MD staff or Pharmacy.
5. Maintained professional costumer service with co-workers and outside vendors.
6. Scheduled delivery of pharmaceuticals to suit patient needs and payer requirements.
7. Communicated clinical inquiries to pharmacy or nursing team and arrange for direct patient communication.

Experience

2-5 Years

Level

Junior

Education

Bachelor Of Arts

Description :

1. Provided responses to patients, as appropriate.
2. Identified opportunities for counseling by Registered Pharmacists or Nurse Counselors and make referrals as appropriate.
3. Built and maintained effective business relationships with prescribers treating assigned set of disease states, and provide ongoing communication of specific case-related information as appropriate.
4. Processed medical authorization requests by reviewing, coding, and inputting data into the system using standard policies, procedures, and guidelines.
5. Verified patient's eligibility and claims status with insurance agencies.
6. Received requests for prior authorizations and ensure that they are properly and closely monitored within company set standards.
7. Reviewed accuracy and completeness of information requested and ensure that all supporting documents are present.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Assigned Authorizations to nurses from Daily Inpatient Census Report Sent denial letters to patients and providers Calculated Procedures, Durable Medical Equipment, and patient services on Excel spreadsheet for Daily Inpatient Census Report and Back log Assignment.
2. Provided weekly updates to team regarding changes within the company and new policies and procedures.
3. Handled incoming calls from providers requesting authorizations.
4. Received a high volume of incoming calls from referrals, doctors' offices, patients, and insurance companies regarding patient's durable medical equipment.
5. Verified prescriptions and work orders in content manager.
6. Keyed intakes for durable medical equipment and CPAP supplies.
7. Pushed work orders to logistics and local branches.

Experience

10+ Years

Level

Senior

Education

Associates Of Occupational

Description :

1. Received calls from patients , doctors,pharmacist, nurses.
2. Resoleved issues & provided approvals & or denials when appropriate.
3. Transferred callers & assisted with customer service Accomplishments Hard worker.Always did best forcallers.
4. Performed utilization review precertifcation via web, fax and telephone according to medical necessity criteria.
5. Referred cases to physcian when treatment requested did not meet medical necessity guidelines Coordinated the appeal process with the requesting.
6. Worked with customer quality to verify patient's demographics, authorizations, delivery, and durable medical equipment.
7. Obtained pre-authorizations with insurance for non-covered medications Assisted with billing for monthly exchanges Maintained records of all pre.

Experience

2-5 Years

Level

Executive

Education

Early Childhood Studies

Description :

1. Worked Closely as a team authorizing surgeries, and Office visits to various Specialist.
2. Answered incoming calls from providers and work from start to finish any urgent authorizations that may be needed for same day appointments or surgeries.
3. Assisted with overtime as needed, and any additional work flow to help get the prior authorization department back in to compliance per AHCCCS guidelines lifting a notice to cure AHCCCS placed on UPH.
4. Worked very closely with other departments to make the memberproviders experience as simple as possible.
5. Assisted with training of new employees, checking the work to verify they are entering each type of authorization correctly.
6. Trained different software programs, explained UPH, AHCCCS, Medicare, and a private health plan to new employees.
7. Trained to run reports for compliance using Microsoft Excel and Oracle reporting software, Sorting out each different health plan creating a pend report, and a base report to pull from form auditors.

Experience

2-5 Years

Level

Executive

Education

Claims Customer Service

Description :

1. Reviewed clinical notes to make sure they are accurate.
2. Coordinated billing and authorizations for Workman's Compensation cases.
3. Obtained prior authorizations from various insurance companies by submitting clinical information via fax or speaking directly to a case management representative.
4. Appealed adverse outcomes.
5. Discussed insurance matters with patients ensuring that they understand their benefits, account balances and the prior authorization approvals, denials, and appeals.
6. Trained the front desk staff to ensure a seamless process for the patients, clinicians, and billing staff.
7. Served as a liaison between a 3rd party biller and the practice.

Experience

2-5 Years

Level

Executive

Education

Women's Studies

Description :

1. Approved and disapproved medical claims for active duty service members and veterans.
2. Created and coordinated approval/disapproval letters.
3. Used Computer knowledge, in how to operate and the software enclaves, in which sensitive items are kept.
4. Reviewed structur clinical data matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation) .
5. Answered calls from physician offices, hospitals /site of care, and patients using exemplary customer service skills.
6. Scheduled doctor lunches with pharmacy reps.
7. Handled inbound phone calls, Written inquires from pharmacist and doctors regarding prior authorization.

Experience

7-10 Years

Level

Management

Education

Certificiate

Description :

1. Responsible for gathering all information required on the authorization, Verifying the correct authorization form and plan to submit authorization through.
2. Completed authorization form or Prior authorization via online or over the phone to insurance company.
3. Responsible for organizing, maintaining, and verifying all aspects of the credentialing process for healthcare providers.
4. Notified appropriate staff of approved/denied medications.
5. Responsible for all follow up phone calls of the authorization and documentation into CPR+ of authorization status.
6. Responsible for maintaining required spreadsheets.
7. Updated Sales Staff with pertinent information.

Experience

7-10 Years

Level

Management

Education

Certification