Claudio Mendez

• Manage the submission and follow-up of prior authorization requests for medication and Psychometric testing
• Collaborate with healthcare providers, insurance companies, pharmacies, and patients to ensure all necessary documentation is gathered for prior authorization, as well as verifying patients' eligibility for benefits.
• Review and evaluate insurance policies and guidelines to ensure compliance with coverage requirements and provide recommendations to providers to ensure PA approval.
• Track and document all approvals, denials, and appeals and set up peer-to-peer if required; produce clinical letters for appeals.

EHR: Tebra

• Managed utilization review processes to ensure all substance abuse treatment services were medically necessary, appropriately documented, and aligned with insurance Requirements.
• Submitted initial, concurrent, and retrospective authorizations in a timely and efficient manner using payor portals, by phone or by fax. Monitored client progress and ensured compliance with payer requirements.
• Collaborated with clinical and administrative teams to facilitate communication with insurance companies, prevent denials, and maintain accurate documentation to secure coverage for services.
• Submitted appeals or scheduled peer-to-peer meetings when necessary to overturn denials.

• Follow up on outstanding workers' comp and no-fault claims; sent paper claims as well as electronic Claims using EHR/ Billing systems.
  Verified patients' eligibility for benefits
  
• Review medical records and fax to insurance when needed. review EOB’s for payment posting.
  
• Appeal denied claims. Apply appropriate Diagnostic codes, procedure codes, and Modifiers as per Superbill provided, and make changes as needed for correct claim processing as per CMS guidelines. Verify workers' compensation and no-fault claims.