Detail-oriented Revenue Cycle Professional with 4 years of specialized experience in insurance verification, prior authorization, eligibility determination, and patient benefit breakdowns. Highly proficient in navigating major web-based web portals and executing direct phone inquiries to confirm active coverage, deductibles, copays, co-insurance, and out-of-pocket maximums.
Adept at identifying coordination of benefits (COB) issues, verifying prior authorization requirements, and reducing claim denials to ensure maximum reimbursement and seamless patient intake.
Payer Portal Verification: Availity, UHC Provider Portal, Cigna Access, Phreesia, BlueE, BlueShield CA, NaviNet, TriZetto, and Tricare etc.
Direct Representative Inquiries: Outbound calls to commercial and government payers for complex benefit breakdowns, policy limitations, and specialized authorizations.
Coverage Verification: Active/inactive status checks, primary/secondary COB determination, deductible tracking, copayments, co-insurance, out-of-pocket limits, and network status.
Compliance & Data Integrity: Strict adherence to HIPAA guidelines, patient account documentation, and EHR/PMS data updating. Key Accomplishments & Bullet Points Conducted comprehensive eligibility and benefit verifications via primary payer portals and real-time electronic EDI transactions, processing high volumes of patient accounts daily.
Executed phone calls directly to insurance representatives to resolve complex benefit discrepancies, clarify non-covered services, and verify retro-eligibility or specialized plan terms.
Utilized Phreesia to streamline digital patient registration, intake workflows, and automated real-time insurance checks. Identified and updated accurate primary, secondary, and tertiary payer hierarchies, resolving Coordination of Benefits (COB) conflicts prior to patient appointments.
Confirmed prior authorization and referral requirements per payer guidelines, coordinating with clinical staff to prevent service delays and coverage denials. Accurately documented detailed benefit breakdowns into the Practice Management System/EHR, maintaining a high level of quality assurance and HIPAA compliance.
Prior Authorization Specialist | End-to-End Payer Portal Management
Portal Mastery: Expert in managing end-to-end portal workflows across major insurance platforms, including Availity, Carelon, Evicore, Cohere Health, and Navinet etc.
End-to-End Workflow Management: Proficient in patient intake, real-time eligibility verification, clinical note extraction, initial request submission, retro-authorizations, and appeal/peer-to-peer scheduling.
Clinical & Coding Knowledge: Strong foundation in CPT, HCPCS, and ICD-10 coding, matching patient charts against specific payer clinical guidelines and LCD/NCD criteria.
Denial & Appeals Resolution: Proactive in tracking authorization statuses, resolving pending requests, and preparing clinical appeal packets to overturn coverage denials.
Compliance & Efficiency: Maintains strict HIPAA compliance while delivering high daily throughput and reducing authorization turnaround times.
Verified
