Sr. Complex Advocate Resume Example

• Performed intake duties, examined incoming faxes from hospitals, (SNF) Skilled Nursing Facilities, Home Health Agencies, Mental/Behavioral Health Facilities, and Rehabs, (DME) Durable Medical Equipment, applied and processed Inpatient Notification request, and prior authorizations for Outpatient services, triaged calls, & coordinated cases ensuring clinical criteria is met for Case Management.
• Approved and denied pharmaceutical pre-authorization through Magellan Rx Management. Collaborated with the department supervisor in the development and revision of existing workflows and the (SOP) Standard Operating Procedures.
• Recognized by management for providing quality and exceptional service in case management.

• Worked daily imaging reports and work queues with DSN (Decision Support Number) info for prior authorization processing. Performed telephonic support for online benefits verification of services regarding utilization, authorizations, and referral activities. Prepared patient assessment packets in hospital settings.
• Verified and entered patient demographics, using electronic health record (EHR) databases, maintained a master patient index while processing and scanning charts, communicating with healthcare providers, implementing hospital standards, maintaining patient information confidentiality, and acquired patient admissions consent forms.
• As the sole contributor for Radiology, Cath Lab, Hyperbaric, & OB Testing Unit work queues, I accurately processed and cleared requests in a timely and efficient manner. Collaborated with the Inpatient team and coordinated notification for non-complex services regarding Inpatient Care in a timely manner.
• Interpreted and submitted clinical documentation pertaining to the specific services requiring prior authorization to support medical necessity reviews by the payer. Obtained and documented pre-certification of services and prior authorization approval from insurance companies for procedures and hospital stays. Notified Physician's office when authorization is not obtained and/or benefits are inadequate.
• Maintained all authorization/notification-related faxes and other documentation in order to support the appeals process in case a claim's denial is received. Resolved claim denials related to the prior authorization process including appeal preparations and submission.

Lead Patient Coordinator Float

• Promoted to lead trainer for the outperformance of 20 floats, due to consistency in ranking number one with productivity in audits and quality standards. As the lead trainer coached, mentored, and oversaw all on-the-job training for 16 new employees.
• Conducted monthly and 60 day audits on new trainees, regarding registration & insurance quality performances. Traveled as a Patient Service Coordinator Float in approximately 26 ancillary clinics throughout the hospital and metro area.
• Registered patients in Epic system, scheduled appointments, prepared documents, verified third-party reimbursement, authorization for care, and billing.
• Requested regularly by the Senior Care Clinic Staff due to demonstrating integrity, compassion, and patient demeanor with patients who were treated with memory problems, chronic illness, falls, & complex drug regiments.

• Facilitated patient registration and scheduling referrals and appointments in-person and by multi-line phone system, in a fast-paced dental office. Also, collected patient data, maintained filing systems, stored charts/records manually and by electronic health record database, and retrieval of patient medical records when required.
• Recognized for showing the most compassion and tact dealing with disabled, elderly, and emotional customers.
• Investigated and verified member eligibility and benefits for Medicaid by using the State's system MN-ITS on a daily basis. Also verified third-party commercial dental payer's via telephone and by fax including Delta Dental, Metlife, Blue Cross Blue Shield, United Healthcare, CIGNA, Aetna.
• Utilized working knowledge of claims processing and accurately identified and applied payments, patient responsibility portions, contractual write offs, adjustments, and timely follow-up for claim denials.
• Received the most "Going the Extra Smile" awards & bonuses, voice mails, gifts, and hand-written notes out of 45-50 staff members in the clinic.