Amanda Irwin, RDH (NC5433)

As a Prior Approval Claims Analyst, I maintain compliance with internal controls, specifically for NC Medicaid, with regard to policy and government regulations. Support and implement efforts to safeguard beneficiaries' access to medically necessary dental services, within the guidelines of Medicaid billing, through prior authorization review initiatives.

• Review and analyze dental radiographs, clinical charting, documents, and attachments to determine eligibility for prior authorization.
• Manage time effectively to ensure tasks are completed on schedule, and deadlines are met daily.
• Participate in multidisciplinary team meetings to discuss complex cases requiring prior authorization.
• Coordinated resolutions for issues and appealed denied authorizations.
• Coordinate with healthcare providers to gather necessary patient information for prior authorization requests, and guidance on request correction when needed.

As a Claims Specialist, I am partnered through Constellation Quality Health, formerly CCME, with State Medicaid agencies to maintain program integrity and prevent payment of claims to providers with potentially fraudulent billing practices by examining claims, treatment plans, radiographs, and referrals prior to payment in areas:

• Prepayment Claims Reviews
• Post-payment Reviews.
• Analyze clinical charts and radiographs to detect anomalous patterns and errors in provider data, which could indicate fraudulent activity.
• Created reports detailing key insights gained through the analysis of data related to fraud incidents and cases handled by the department with regard to Medicaid providers under review.
• Analyzed claim documents for completeness and compliance with applicable standards.