Alexys Redford
Cape Coral,FL
Summary
Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
6
6
years of professional experience
Work History
Prior Authorization Specialist
Lee Health
Fort Myers, FL
01.2022 - Current
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Provided guidance to providers regarding the prior authorization process.
- Responded promptly to inquiries from providers, patients and payers regarding status of prior authorization requests.
- Processed appeals in a timely manner as per policy guidelines.
- Maintained accurate records of all authorization activities in the database system.
- Researched clinical criteria and determined eligibility for requested services based on plan provisions.
- Collaborated with internal staff members to resolve discrepancies or issues related to prior authorizations.
- Ensured compliance with state and federal regulations pertaining to prior authorizations.
- Identified areas where improvements can be made within the department by analyzing trends in denials and approvals.
- Advised provider offices on proper coding practices that are necessary for successful claim submission.
- Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Coordinated resolutions for issues and appealed denied authorizations.
- Scheduled patient appointments, diagnostic specialty appointments, tests and procedures.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
- Notified ordering providers of denied authorizations.
- Used Epic to input claim, prior authorization and other important medical data into system.
- Maintained confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
- Proofread documents carefully to check accuracy and completeness of all paperwork.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
- Demonstrated leadership by making improvements to work processes and helping to train others.
- Prioritized and organized tasks to efficiently accomplish service goals.
- Maintained updated knowledge through continuing education and advanced training.
- Motivated and encouraged team members to communicate more openly and constructively with each other.
- Reviewed patient's prescription for accuracy and completeness, verifying that all information is correct.
Lead Certified Pharmacy Technician
Publix Pharmacy
Fort Myers, FL
01.2018 - 08.2022
- Provided direct supervision and training to pharmacy technicians.
- Maintained accurate records of prescription orders and inventory.
- Assisted in the development and implementation of policies, procedures, and protocols related to medication management.
- Performed quality assurance checks on medications prior to dispensing.
- Communicated with physicians regarding prescription refills and other inquiries.
- Processed insurance claims for prescriptions filled at the pharmacy.
- Maintained patient profiles, including allergies, current medications.
- Ordered drugs from wholesalers or manufacturers when needed for patient care.
- Received incoming shipments of drugs from wholesalers or manufacturers.
- Conducted physical inventories of controlled substances according to established schedules.
- Verified accuracy of data entry into computer system for new prescriptions.
- Answered phone calls from customers seeking advice about their medications.
- Generated reports detailing sales, profits, inventory levels., as requested by management.
- Became certified in giving vaccinations
Education
Pharmacy Technician
Cape Coral Technical College
Cape Coral, FL12-2017
Skills
- Workflow Optimization
- Insurance Billing
- Drug Inventory Control
- Interpreting orders
- Pharmaceutical Calculations
- HIPAA
- FDA Drug Safety Guidelines
- New Hire Onboarding
- Problem-solving skills
- Resolving customer issues
- Team Collaboration
- Training and mentoring
- Data Verification
- Document Management
- Data Entry
- Clinical Documentation
- Medical Terminology
- Leadership
- Organizational Skills
- Relationship Building
- Problem-Solving
- Remote Office Availability
- Written Communication
- Decision-Making
References
References available upon request.
Timeline
Prior Authorization Specialist
Lee Health
01.2022 - Current
Lead Certified Pharmacy Technician
Publix Pharmacy
01.2018 - 08.2022
Pharmacy Technician
Cape Coral Technical College