Andrea Dorcas
Albuquerque,NM
Summary
Efficient Precertification Specialist with extensive experience at New Mexico Orthopaedics. Known for swift and productive handling of tasks. Skill set includes comprehensive knowledge in insurance verification, medical coding (ICD-10, CPT), and patient records management. Excel in communication, time management, and problem-solving, ensuring seamless preauthorization processes that facilitate patient care coordination and billing accuracy
Overview
23
23
years of professional experience
Work History
Pre Certification Specialist
New Mexico Orthopaedics
Albuquerue, NM
12.2022 - Current
- Reviewed medical documentation for precertification compliance and accuracy.
- Coordinated with healthcare providers to obtain necessary patient information.
- Processed precertification requests using electronic health record systems.
- Communicated with insurance companies regarding policy requirements and updates.
- Educated patients on precertification procedures and potential outcomes.
- Verified insurance eligibility, coverage levels, and benefit parameters prior to submission of precertification requests.
- Reviewed patient medical records to determine medical necessity for requested services and procedures.
- Ensured compliance with all HIPAA regulations pertaining to protected health information.
- Assisted with answering provider inquiries regarding preauthorization requirements and processes.
- Compiled and submitted precertification requests for review by payers in accordance with established timelines.
- Evaluated clinical criteria against existing health plan guidelines to determine authorization status.
- Processed appeals when necessary following denial or rejection of claims due to lack of proper authorization.
- Explained reasons behind application denials and recommended further action.
- Explained eligibility details and affordability options to patients with kindness and respect.
Office Administrator
Hanger Prosthetics and Orthotics
Albuquerque, NM
04.2015 - 10.2021
- Duties consisted of insurance eligibility & authorizations, Patient appointments, managing incoming calls, scanning & filing patient documents and ensuring complete and accurate information, daily document research on the electronic health/medical record system, verifying that all codes HCPS and ICD-10 were entered correctly prior to billing to ensure clean claims for billing.
- Reviewing denied claims for additional information that was sent for review per payer requirements; Make corrections as needed.
- Provided financial counseling to the patient who needed it and set those up on a payment payment plan.
- Posting insurance payments as well as over the counter payments.
- Daily tasks that required reviewing & managing incoming documents and tasking appropriate parties to outstanding requests for information.
- Calling the referring providers office to follow up on documentation that was sent to them for signatures.
Accounts Receivable
Albuquerque Health Partners
Albuquerque, NM
12.2013 - 03.2015
- Contacting the insurance companies of denied claims, resolving the issue and resubmitting claims for payment.
Presbyterian HealthCare
01.2003 - 01.2013
- Company Overview: Advancing positions at Presbyterian HealthCare Services throughout my career
- Presbyterian Neurology 2012-2014
- Presbyterian Kaseman - PMG - Lead Resource Specialist 2008 - 2012
- Presbyterian Kaseman Family Practice - 2003 - 2008
- Advancing positions at Presbyterian HealthCare Services throughout my career
Education
High School -
Sandia High School
Albuquerque, NM01.1990
Skills
- Professional and self-directed
- Insurance Verifications - Insurance Portals
- Precertification processing
- Insurance policy communication
- Prior authorization
- Medical terminology
- Medical billing
- Knowledgeable of Excel
- Microsoft Word
- Data entry
- Medical terminology proficiency
References
- Sara DeVore, (505) 385-2713
- Debbie Wade, (505) 459-4383
- Tammra Hindmarsh, (505) 328-5197
Timeline
Pre Certification Specialist
New Mexico Orthopaedics
12.2022 - Current
Office Administrator
Hanger Prosthetics and Orthotics
04.2015 - 10.2021
Accounts Receivable
Albuquerque Health Partners
12.2013 - 03.2015
Presbyterian HealthCare
01.2003 - 01.2013
High School -
Sandia High School
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