Prior Authorization Coordinator Resume Samples

Description :

1. Promoted quality and cost-effectiveness of medical care through adherence to utilization management protocols.
2. Executed Prior Authorization processes to ensure timely and appropriate care delivery.
3. Communicated effectively with provider groups and health plans to resolve authorization inquiries.
4. Processed requests for approval, denial, or deferral, ensuring timely resolution.
5. Managed deferred authorization maintenance, including tracking and follow-up.
6. Applied client and corporate guidelines to determine approval or denial of medication requests.
7. Collaborated with clinical program managers to address complex authorization issues.

Experience

0-2 Years

Level

Entry Level

Education

AAS Health Admin

Description :

1. Communicated with patients to gather essential information for processing prescriptions, refills, and applying co-pay cards, fostering loyalty through exceptional service.
2. Investigated and verified benefits for pharmacy and medical claims, ensuring accuracy and compliance with payer requirements.
3. Coordinated with financial assistance teams to secure funding for patients requiring medication support.
4. Initiated and followed up on authorization requests, maintaining communication with insurance carriers to expedite decision-making.
5. Monitored and reported service issues related to authorizations, advocating for timely resolutions to prevent delays in patient care.
6. Ensured consistent patient access to medications and therapies, minimizing interruptions in treatment.
7. Maintained detailed records of interactions and outcomes to support continuous improvement initiatives.

Experience

5-7 Years

Level

Senior

Education

BSHA

Description :

1. Processed internal and external requests for injectable drugs, ensuring compliance with insurance guidelines.
2. Completed insurance forms for various providers, including Blue Cross and Cigna, to facilitate approvals.
3. Reviewed patient charts to identify necessary lab tests and documentation for authorizations.
4. Documented all communications with medical staff and pharmacies to maintain accurate records.
5. Delivered exceptional customer service to patients and vendors, fostering strong professional relationships.
6. Coordinated the timely delivery of pharmaceuticals in alignment with patient needs and payer requirements.
7. Communicated clinical inquiries to pharmacy and nursing teams, facilitating direct patient interactions.

Experience

0-2 Years

Level

Junior

Education

A.S. in Health Sci.

Description :

1. Managed and processed prior authorization requests, ensuring adherence to regulatory standards.
2. Established and nurtured relationships with healthcare providers to facilitate timely authorizations.
3. Conducted thorough reviews of patient eligibility and insurance claims, resolving issues proactively.
4. Implemented process improvements that enhanced operational efficiency and reduced turnaround times.
5. Monitored and maintained accurate records of authorizations, ensuring compliance with internal policies.
6. Collaborated with interdisciplinary teams to address complex authorization challenges.
7. Provided training and support to junior staff on best practices in prior authorization coordination.

Experience

7-10 Years

Level

Management

Education

B.S. Health Admin.

Description :

1. Managed daily assignments of prior authorization requests for medical services and durable medical equipment.
2. Provided comprehensive updates to the team on policy changes, enhancing compliance and operational efficiency.
3. Handled high volumes of inquiries from healthcare providers, patients, and insurance companies regarding authorization status.
4. Verified prescriptions and documentation to ensure accurate and timely processing of authorizations.
5. Entered and tracked durable medical equipment requests in the management system.
6. Coordinated with logistics teams to facilitate timely delivery of medical equipment.
7. Implemented process improvements that increased overall team productivity and reduced errors.

Experience

2-5 Years

Level

Management

Education

B.S. Health Admin.

Description :

1. Managed incoming calls from patients, healthcare providers, and pharmacists to facilitate prior authorization requests.
2. Resolved issues and provided timely approvals or denials based on medical necessity criteria.
3. Maintained accurate records of all pre-authorization activities and outcomes.
4. Conducted utilization reviews for pre-certifications via web, fax, and telephone.
5. Coordinated appeals with physicians when treatment requests did not meet medical necessity guidelines.
6. Worked with quality assurance teams to verify patient demographics and authorization details.
7. Obtained pre-authorizations with insurance for medications and assisted with billing inquiries.

Experience

0-2 Years

Level

Entry Level

Education

A.S. in HA

Description :

1. Collaborated with healthcare teams to authorize surgeries and office visits efficiently.
2. Managed urgent authorizations for same-day appointments, ensuring timely patient care.
3. Contributed to compliance efforts by addressing AHCCCS guidelines, significantly improving departmental operations.
4. Streamlined communication between departments to enhance member experience.
5. Trained new hires on authorization processes, ensuring accuracy and compliance.
6. Utilized reporting tools to analyze authorization data and support compliance initiatives.
7. Conducted follow-ups on pending authorizations to optimize workflow and patient access.

Experience

0-2 Years

Level

Entry Level

Education

AAS-HIT

Description :

1. Reviewed and validated clinical notes for accuracy to ensure compliance with authorization requirements.
2. Coordinated billing and prior authorizations for Workers' Compensation cases, enhancing claim efficiency.
3. Submitted clinical information to various insurers to obtain prior authorizations, utilizing effective communication strategies.
4. Managed appeals for adverse outcomes, advocating for patient needs and ensuring fair resolutions.
5. Educated patients on their insurance benefits and prior authorization statuses, fostering transparency and trust.
6. Trained front desk staff on authorization processes to improve patient experience and operational flow.
7. Acted as a liaison between third-party billers and healthcare providers to streamline billing processes.

Experience

2-5 Years

Level

Junior

Education

BSHA

Description :

1. Processed and evaluated medical claims for service members and veterans, ensuring compliance with insurance policies.
2. Drafted and dispatched approval/denial letters to patients and providers to facilitate clear communication.
3. Utilized software systems to manage sensitive data and ensure secure documentation.
4. Analyzed clinical data against medical terminology and codes to ensure accurate processing.
5. Provided exceptional customer service by addressing inquiries from healthcare providers and patients.
6. Coordinated meetings between doctors and pharmacy representatives to enhance collaborative care.
7. Managed incoming inquiries regarding prior authorizations, providing timely and accurate information.

Experience

0-2 Years

Level

Entry Level

Education

A.S. Health Sci.

Description :

1. Gathered and verified all necessary information for insurance authorizations, ensuring accuracy and compliance.
2. Completed prior authorization requests via online platforms and phone calls to insurance providers.
3. Maintained and organized all aspects of the credentialing process for healthcare providers.
4. Informed relevant staff of authorization approvals or denials for timely response.
5. Conducted follow-up calls to check authorization statuses and documented updates in the CPR system.
6. Managed spreadsheets to track authorization requests and outcomes efficiently.
7. Communicated pertinent information to sales staff, ensuring alignment with patient needs.

Experience

0-2 Years

Level

Entry Level

Education

A.S. in Health Science

Description :

1. Obtained referrals and/or precertification of ordered services such as office visits, procedures, therapies, referrals, radiology tests and medications for MCR/MCD, MCR/MCD products, commercial carriers and occasionally BWC.
2. Kept current on various clinical guidelines, CPT & ICD-9 coding practices.
3. Liaisoned between staff, insurance carriers and patients regarding insurance policy practices, precertification processing and/or an appeal process.
4. Created documents for efficiency of precertification(s)/appeals, spreadsheets/graphs for statistical purposes, forms and form letters.
5. Scanned and assigned documents into the McKesson EMR system.
6. Verified insurance eligibility/benefits.
7. Able to implement my own templates and computer set up for the highest efficiency.

Experience

5-7 Years

Level

Junior

Education

Diploma

Description :

1. Provided necessary information for authorization and stay/visit re-authorization.
2. Reviewed information for admission and visit management including type and duration of service, authorization and treatment codes, re-authorization and visit requirements necessary for ongoing treatment and payment.
3. Actively membered in a patient-centered-team approach in the care of the patient and families.
4. Worked collaboratively with all team members in achieving shared goals with a consistent focus on quality care.
5. Participated in quality improvement activities including data analysis, implementing recommendations, evaluating changes and outcomes.
6. Experienced in ambulatory/physician office setting preferred. 
7. Knowledged of insurance and managed care companies preferred.

Experience

2-5 Years

Level

Executive

Education

GED

Description :

1. Primary contacted outpatient families regarding insurance referring them to the patient accounting department as needed.
2. Responsible for obtaining complete and accurate insurance information, benefits verification, accurately interpreting benefit plans, and investigating pertinent details.
3. Notified supervisor of known or potential insurance coverage issues.
4. Reviewed information for admission and continued visit management including type and duration of service, authorization and treatment codes, re-authorization, and continued visit requirements necessary for ongoing treatment and payment.
5. Responsible for explaining benefits, the billing process, and financial responsibility to parent/guardian.
6. Responsible for obtaining and communicating pre-authorization as needed per insurance company requirements.
7. Worked with a lot of elderly patients and if I could just make one person's day I felt like I accomplished a whole lot.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Involved communication with Commercial Insurance Companies and Workers Compensation Nurse Case Managers to verify patient coverage and benefits.
2. Demonstrated and completed training processes for Knowledge of ICD9 diagnosis coding Knowledge of CPT4 procedural coding Knowledge of Medical terminology Ability to summarize clinical information in writing or orally for Medical Management or Adjusters Knowledge of Mysis and Tiger computer software from registration through finalization of printing charge tickets Required extensive knowledge of medical billing and follow-up, practice management, accounts receivables, in addition to other accounting procedures such as accounts payable and account reporting used for orthopedic practices.
3. Reviewed of accounting skills see Hertford Gates Health Department on Other related employment.
4. Responsible for checking insurance eligibility for outpatients at least every 90 days and annually in January and July via electronic medical records and insurance websites.
5. Appealed for additional services (extended stays, visits, authorization extension, and letter of medical necessity) and refers to additional resources when necessary.
6. Progressed through career ladder from Rep to Coordinator in three years Responsible for reinventing the training process for new employees, and creating paperless reference and training material.
7. Worked with insurance companies and MD offices to obtain authorizations for patient's needed medical tests and procedures.

Experience

2-5 Years

Level

Junior

Education

MS