Carolina Villegas
Pacoima,CA
Summary
Prior Authorization Specialist with over 20 years of experience in healthcare. Skilled in multitasking and training team members, ensuring compliance with protocols while maintaining professionalism and a high level of customer service. Responsible for assisting with the delivery of quality health care services, responsible for supporting the clinician reviewers and medical directors as a resource for clarification and researching complex member referral history for additional information needed in order to review the request based on medical necessity. Monitor all assigned referrals to ensure regulatory turnaround time compliance, assist with expending finalization of referrals, and monitor requests that may require additional information prior to Regional Medical Director finalization. Work in collaboration with the department Prior Auth Coordinators, Team Leads, Supervisors, Department Director, Offshore Teams, Prior Authorizations Nurses, Director, Offshore Teams, Prior Authorization Nurses, Regional Medical Directors, and Network Managers to assist with daily operations and assuring a level of referral processing that meets or exceeds the organization's expectation.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Prior Authorization Specialist
Lakeside Medical Group
Northridge, CA
01.2023 - 04.2026
- Processed prior authorization requests efficiently, ensuring adherence to medical guidelines and protocols.
- Collaborated with healthcare providers to gather necessary documentation for approval.
- Analyzed patient data to determine eligibility and necessity for requested services.
- Trained new team members on procedures and best practices for authorization workflows.
- Collaborated with physicians to obtain necessary clinical information for prior authorization submissions.
- Verified eligibility and compliance with authorization requirements for service providers.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Managed a high volume of incoming calls, maintaining professionalism while effectively addressing the needs of callers seeking assistance with prior authorizations.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Contributed to a high level of customer service by quickly addressing questions or concerns from patients regarding their coverage or denials.
- Improved patient satisfaction with timely and accurate processing of prior authorizations for medications and procedures.
- Scheduled appointments with applicants to gather information and explain benefits processes.
Authorization Coordinator
Lakeside Medical Group
Northridge, CA
04.2011 - 2022
- Coordinated patient authorization requests, ensuring compliance with insurance requirements.
- Processed prior authorization submissions using electronic health record systems.
- Collaborated with medical staff to gather necessary documentation for approvals.
- Communicated effectively with insurance companies to resolve authorization issues.
- Collaborated with multidisciplinary teams to ensure timely submission of documentation required for insurance approval.
- Provided training and support to new team members on authorization protocols.
- Maintained consistent follow-up on status of prior authorization requests.
- Gathered records pertinent to specific problems, reviewed for completeness and accuracy and attached records to correspondence as necessary.
Durable Medical Equipment Coordinator
Lakeside Medical Group
Glendale, CA
03.2008 - 03.2010
- Collaborated with departments to assess and fulfill equipment needs
- Prior Authorization Processing for medical equipment
- Eligibility and Benefit verification
- Co-pay verification
- Calling providers to ensure they provide services requested
- Customer service
EIOD Coordinator
Lakeside Medical Group
Glendale, CA
01.2006 - 09.2008
- Coordinated patient scheduling and managed appointment .
- Assisted in maintaining accurate patient records using electronic health record systems.
- Communicated with healthcare providers and Members to ensure seamless information exchange regarding patient care.
Education
Administrative Clerk
Adelante Career Institute
Van Nuys, CASkills
- Prior authorization
- Authorizations
- Insurance verification
- Effective communication skills
- Patient referrals
- Data entry
- Electronic health records proficiency
- Physician order verification
- Benefit coverage
- Professionalism and ethics
- Patient scheduling
- Claim research
- Critical thinking
- HIPAA compliance
- Precertification requirements
- Referral coordination
- Multitasking
- Problem-solving
- Appointment scheduling
- Documentation and paperwork
- Teamwork
- Customer service
- Attention to detail
- Problem-solving abilities
- Multitasking ability
- Reliability
- Excellent communication
- Active listening
- Decision-making
- Computer proficiency
- Documentation skills
- Self motivation
- Professionalism
- Adaptability
Accomplishments
Collaborated with team of 9 in the development of better process of prior authorization process for High Risk Members.
Certification
Prior Authorization Specialist for High Risk Members
Languages
English
Professional Working
Spanish
Professional Working
Timeline
Prior Authorization Specialist
Lakeside Medical Group
01.2023 - 04.2026
Authorization Coordinator
Lakeside Medical Group
04.2011 - 2022
Durable Medical Equipment Coordinator
Lakeside Medical Group
03.2008 - 03.2010
EIOD Coordinator
Lakeside Medical Group
01.2006 - 09.2008
Administrative Clerk
Adelante Career Institute