Demetrus Robinson
Opelika
Summary
Dedicated professional with a proven track record of achieving company objectives through consistent and organized practices. Expertise in thriving under pressure while adapting to new challenges, enhancing the organizational brand with a positive attitude. Reliable candidate known for effectively managing multiple priorities and demonstrating excellent communication and sound judgment. Over 10 years of experience as a Prior Authorization Specialist, adept at collaborating with insurance representatives to secure preapproval for procedures, showcasing strong organizational skills and a commitment to team success.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Prior Authorization Specialist
Blue Cross and Blue Shield
11.2024 - Current
- Input all patient data regarding claims and prior authorizations into system accurately.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Answered incoming phone calls and addressed questions from customers and healthcare providers.
- Resolved third-party billing, computer system and customer service issues.
- Assisted clients with completion of applications and paperwork.
Pharmacy Technician, Prior Authorization Reviewer
Acentra
04.2023 - 11.2024
- Answered incoming phone calls and addressed questions from customers and healthcare providers.
- Solved customer problems over telephone by providing assistance with navigating systems and locating items.
- Entered and processed patients' prescriptions into internal system.
- Communicated with prescribers to verify medication dosages, refill authorizations and patient information.
- Consulted with insurance company representatives to complete claims processing, resolve concerns
- Resolved non-routine issues like third-party billing, computer system and customer service issues.
- Set up and modified patient profiles in System to include current information such as medications and insurance details.
- Provided consultations and answered inquiries from patients, healthcare professionals and physicians regarding drugs, potential side effects and specified use.
- Answered telephones and responded to inquiries from patients, healthcare providers, pharmacies, insurance companies and other customers.
- Resolved customer service issues regarding prescription refills or discrepancies between ordered drugs and dispensed drugs.
- Entered data into computer systems to maintain accurate records of medications prescribed and dispensed.
- Verified patient demographic and insurance information to ensure accuracy of prior authorization requests.
- Processed incoming faxes for new prescriptions and prior authorization requests.
- Conducted follow-up calls with physicians' offices regarding incomplete or missing information on prescriptions.
- Interpreted health plan benefits and coverage requirements related to prior authorization process.
- Maintained current knowledge of changes within the healthcare industry related to the prior authorization process.
- Provided customer service support by responding promptly and professionally to inquiries from patients, physicians' offices, insurance companies. via phone or email.
- Ensured that all required documents were obtained before submitting a request for approval of medications requiring preauthorization.
- Collaborated with other departments such as billing, clinical staff, and providers in order to ensure successful completion of the prior authorization process.
- Evaluated non-formulary drugs based on cost effectiveness compared with formulary drugs when necessary during the authorization process.
- Participated in educational programs designed to increase understanding of drug utilization management policies and procedures associated with the prior authorization process.
Prior Authorization Pharmacy Technician
KEPRO
04.2018 - 04.2023
- Verified patient demographic and insurance information to ensure accuracy of prior authorization requests.
- Performed data entry in pharmacy software system to enter prescription orders, patient profiles, and prior authorizations.
- Reviewed physician's office notes for medication history and allergies to ensure safety of patients.
- Processed incoming faxes for new prescriptions and prior authorization requests.
- Interpreted health plan benefits and coverage requirements related to prior authorization process.
- Analyzed prior authorization request forms to determine appropriate coding before submission.
- Interpreted benefit language in order to determine covered services under each plan type.
- Reviewed and processed prior authorization requests according to insurance guidelines.
- Determined medical necessity of requested services by reviewing patient records and corresponding with providers as needed.
- Provided customer service support by responding promptly to provider inquiries regarding authorization status or policy information.
- Maintained a professional attitude when interacting with external customers such as physicians' offices or insurance companies.
- Analyzed clinical data submitted by physician offices in order to approve or deny prior authorization requests.
- Maintained accurate documentation of all prior authorization activities in accordance with established policies and procedures.
- Maximized performance by monitoring daily activities and mentoring team members.
Pharmacy Technician
Health Information Designs, Inc
06.2014 - 04.2018
- Verified insurance coverage for medications.
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Maintained confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
- Coordinated with healthcare providers to gather necessary patient information for prior authorization requests.
- Trained new staff on prior authorization procedures and company policies.
- Reviewed and processed prior authorization requests for medical procedures and medications according to established guidelines.
- Input claim, prior authorization, and other important medical data into system.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Provided excellent customer service to resolve customer complaints in a timely manner.
Customer Service Representative
Health Information Designs, Inc
08.2011 - 07.2014
- Provided excellent customer service to resolve customer complaints in a timely manner.
- Provided customer service by answering incoming calls and responding to inquiries in a timely manner.
- Maintained accurate records of customer interactions, details of inquiries, comments, and actions taken.
- Offered resolutions to de-escalate calls and solve customer issues.
- Ensured compliance with all relevant rules and regulations governing data entry activities.
- Assisted colleagues with resolving any issues related to data entry operations.
- Transferred data from hard copies to digital databases, organizing information in new formats.
- Ensured compliance with regulatory requirements such as HIPAA and DEA regulations.
- Maintained up-to-date knowledge of company products, services, policies, and procedures.
Education
High School Diploma -
Beulah High School
Valley, AL05-2005
Skills
- Patient Confidentiality
- Team Collaboration
- Pharmaceutical Sales and Services
- Problem-Solving Skills
- Clinical Abilities
- Resolving Customer Issues
- Computer Billing Systems
- FDA and HIPAA Compliance
- Records Preparation
- Answering Customer Questions
- Information Documentation
- Resolving Complaints
- Customer Service
- Call Center Operations
- Helpdesk Call Support
- Technical Support and Assistance
- Customer Communication and Empathy
Certification
- Cpht
- Hipaa
Timeline
Prior Authorization Specialist
Blue Cross and Blue Shield
11.2024 - Current
Pharmacy Technician, Prior Authorization Reviewer
Acentra
04.2023 - 11.2024
Prior Authorization Pharmacy Technician
KEPRO
04.2018 - 04.2023
Pharmacy Technician
Health Information Designs, Inc
06.2014 - 04.2018
Customer Service Representative
Health Information Designs, Inc
08.2011 - 07.2014
High School Diploma -
Beulah High School
Education and Training
other
References
References available upon request.
certification
CphT/PTCB Certification # 10055727
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