DAISY PENALOZA

• Processed prior authorization requests following departmental guidelines.
• Processed Surgery Verification.
• Request inquiries, and authorization for clinics, and surgery centers.
• Coordinating surgeries, including communication with the surgical center and outside providers.
• Maintaining the surgery schedule for physicians.
• Data entry of all patient demographics, guarantor, and insurance information must be completed.
• Working with billing staff to identify action plans to address billing errors that result from registration and eligibility activities.
• Triaged emergency and unscheduled authorizations, directing submissions in rapid response.
• Prepared for denial letters, appeal measures, and detaining reasons for denial.
• Resolved conflicts and negotiations resulted in mutually beneficial agreements.
• Provide facility-specific assistance to the project management team as needed, or requested.
• Reviewed prior authorization requests to ensure accuracy and completeness of required information.
• Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
• Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal communication skills.

Utilized ICD-10 and CPT codes to accurately authorize requests for medical procedures, ensuring alignment with payer guidelines, and medical necessity.

• Interpreted and validated diagnosis and procedure codes submitted by providers to determine coverage eligibility and appropriate documentation requirements.

• Responded promptly to internal and external customers via telephone or written communication.
• Authorized surgical requests, following applicable plans and guidelines.
• Fielded telephone inquiries on authorization details from plan members, and medical staff.
• Verified eligibility and requested authorization requirements for service providers.
• Obtained and logged accurate patient insurance and demographic information for insurance procedures and medical personnel.
• Prepared and distributed a denial letter, detailing the reasons for denial, and possible measures.
• Verify any changes or date updates to patient records, and run eligibility information at each appointment.
• Communicated with insurance representatives to resolve authorization issues promptly.
• Utilized ICD-10 and CPT codes to accurately authorize requests for medical procedures, ensuring alignment with payer guidelines and medical necessity.
• Interpreted and validated diagnosis and procedure codes submitted by providers to determine coverage eligibility and appropriate documentation requirements.
• Processed prior authorization requests for various surgical procedures efficiently.
• Reviewed patient medical records to ensure compliance with insurance guidelines.