Description :

1. Processed incoming Commercial and Medicaid Prior Authorization request via phone and fax.
2. Advised Pharmacies and Providers of policy holder benefits.
3. Processed Pharmacy claim rejections.
4. Answered incoming Pharmacy helpdesk inquiries.
5. Verified patient insurance coverage, determines eligibility and benefits.
6. Provided excellent customer service to both internal and external customers.

Experience

7-10 Years

Level

Management

Education

B.S. Health Admin

Description :

1. Confirmed their diagnosis and CPT codes for the requested procedures/ visits and then contact the insurance carriers or case workers to obtain necessary authorizations.
2. Worked with the pain clinics, responsible for creating new accounts for upcoming cosmetic procedures.
3. Processed approvals and denials.
4. Screened and selected intelligence reports and documents to be entered into the INR information handling system.
5. Analyzed data in response to requests for intelligence, research, documents, and other related requirements from Intelligence and Research analysts
6. Able to obtain and maintain a Top Secret security clearance.
7. Processed over 1,500 prior authorization requests monthly, achieving a 95% approval rate.

Experience

2-5 Years

Level

Executive

Education

B.S. in Health Admin

Description :

1. Answered incoming inquiries from providers and policy holders regarding pharmacy benefits.
2. Performed overrides on medications as needed.
3. Educated members, pharmacies and providers on administrative procedures and benefit information for covered procedures and benefits.
4. Responded to all inquiries with professional attitude.
5. Maintained standards of quality and adherence on a monthly basis.
6. Utilized resources to provide quality responses.
7. Maintained accurate records of authorization requests, achieving a 98% accuracy rate in data entry and tracking.

Experience

5-7 Years

Level

Executive

Education

B.S. Health Admin

Description :

1. Received, audited, and processed incoming service authorizations for Medicaid services.
2. Responsible for auditing incoming applications and verifying all required information is submitted.
3. Verified the provider and client information for eligibility as well as current services.
4. Ensured requested services are authorized accurately, research procedure and diagnosis codes for criteria.
5. Researched existing authorizations billing information to ensure services are not duplicated.
6. Sent provider and client authorization information.
7. Communicated, verified the contact information directly with the provider before resending due to HIPPA Laws.

Experience

2-5 Years

Level

Executive

Education

A.S. in HA

Description :

1. Obtained precertification or predetermination as required from third-party payers.
2. Performed investigations into payment denials as well as initiated and followed up written appeals.
3. Researched the medical policies of various payers to maximize reimbursement as well for the purpose of investigating denials.
4. Ensured the proper clinical documentation was in place as needed to obtain preauthorization and queried providers for clarity.
5. Interacted with patients to address questions regarding their authorization or billing questions.
6. Provided information to clients, participants, pharmacists and doctors regarding participants pharmacy benefit, drug coverage and provide accurate procedures for medication exceptions.
7. Reviewed requests from the Department and the U.S. Intelligence community for all-source intelligence across interrelated geographical and functional areas.

Experience

10+ Years

Level

Senior

Education

B.S. in Health Admin.

Description :

1. Obtained timely authorizations from various insurance companies.
2. Communicated with insurance carriers, both internal and external customers and patients via phone or written correspondence.
3. Followed up on insurance determination.
4. Reported to supervisor to assure accurate capture of services needing authorization.
5. Responsible for selecting accurate medical records for patient safety and obtaining and validating demographic and insurance information.
6. Responsible for providing all required medical information to insurance companies as necessary to facilitate the authorization process.
7. Collaborated with healthcare providers to streamline authorization processes, reducing turnaround time by 30%.

Experience

2-5 Years

Level

Executive

Education

BSHA

Description :

1. Processed the prior authorizations for the Duke Raleigh and WakeMed Cary Pain Centers.
2. Responsible for accessing the hospitals' websites to obtain patient information for daily schedules at the clinics.
3. Verified their demographics and insurance or workers compensation eligibility.
4. Researched and confirmed their diagnosis/ICD-10 code(s) and CPT codes for the requested procedures/ visits.
5. Responsible for obtaining medical records and submitting them, along with any necessary request forms, to the carriers for review.
6. Worked with the pain clinics, also responsible for account origination of upcoming cosmetic and prepaid procedures.
7. Contacted to make the payment on the procedure prior to their date of service.

Experience

10+ Years

Level

Senior

Education

B.S. Health Admin.

Description :

1. Answered phone calls from Physicians, Hospital and patient using exemplary customer service skills.
2. Scheduled new patient consultations, sleep studies and follow up appointment with the appropriate providers using a complex scheduling system.
3. Verified patient's insurance benefits and eligibility.
4. Reviewed structured clinical data matching it against specific medical terms and diagnosis or procedure codes and follow established procedures for authorizing request or referring request for further review.
5. Maintained patient confidentiality as defined by state, federal and company regulations.
6. Worked closely with MA's, check in staff along with Insurance companies to check benefits, eligibility for surgeries and other medical procedures.
7. Worked closely with the VA in Salt Lake and the VAC program.

Experience

5-7 Years

Level

Executive

Education

B.S. HA

Description :

1. Processed inbound prior authorization requests via phone and fax.
2. Handled inbound telephone and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria.
3. Facilitated resolution of drug coverage issues and pro-actively address research and resolve issues while maintaining accurate and complete documentation of all inquires for continuous improvement.
4. Worked collaboratively with other associates and supervisor to ensure that best practices are shared.
5. Included authorizing prior approval requests for all injectable medications.
6. Charged for doing the clinical review and entering auto-authorizations.
7. Prepared and coordinated accurate computer generated inventories and is often consulted on the status of intelligence equipment and intelligence critical system supplies.

Experience

10+ Years

Level

Senior

Education

A.A.S. HIT

Description :

1. Contacted insurance carriers to verify patient's insurance eligibility benefits and requirements.
2. Requested, tracked, and obtained pre-authorization from insurance carriers within time allotted for medical services.
3. Requested, followed-up and secured prior-authorizations prior to services being preformed.
4. Worked in collaboration with the medical sites to obtain any additional clinical documentation that can be forwarded to insurance carrier.
5. Provided direct support to Referral Coordinators.
6. Maintained a level of productivity suitable for the department.
7. Managed the Medicare Part D and commercial plans PBM activity and prior authorizations.

Experience

2-5 Years

Level

Executive

Education

B.S. Health Admin