Prior Authorization Representative
Express Scripts / Cigna
- Provided exceptional customer service, addressing inquiries from both patients and healthcare providers promptly and professionally.
- Verified eligibility and compliance with authorization requirements for service providers.
- Ensured compliance with HIPAA regulations by maintaining strict confidentiality in handling sensitive patient information.
- Processed new medication and refill requests for authorization.
- Communicated pertinent information to client's prescribing provider to facilitate quality service.
- Improved patient satisfaction by efficiently processing prior authorization requests and ensuring timely responses.
- Streamlined workflow for faster approval turnaround times, handling high volume of insurance verification tasks.
- Collaborated with healthcare providers to expedite the process of obtaining necessary medical documentation for approvals.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Reduced claim denials by thoroughly reviewing and analyzing medical necessity documentation before submitting for approval, ensuring all criteria were met.
- Reduced errors in documentation by meticulously reviewing medical records and verifying information accuracy.
- Contributed to departmental success by consistently meeting or exceeding performance metrics such as accuracy, productivity, and quality standards.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Facilitated better communication between departments through proactive engagement with other teams involved in the prior authorization process.
- Increased accuracy of insurance coverage validation by utilizing available tools and resources to verify eligibility requirements quickly.
- Supported continuous improvement initiatives by actively participating in meetings, providing feedback, and suggesting areas for improvement.
- Contacted insurance companies to obtain prior authorization for medical procedures and medications.
- Developed strong relationships with key stakeholders such as physicians, nurses, pharmacists, and office managers to support seamless coordination during the prior authorization process.
- Enhanced team productivity with thorough training of new staff members on company policies and procedures.
- Maintained up-to-date knowledge of industry trends, regulatory changes, and payer-specific guidelines to ensure accurate processing of requests.
- Tracked referral submission during facilitation of prior authorization issuance.
- Assisted management in implementing new processes and software systems, increasing overall efficiency within the department.
- Participated in ongoing professional development opportunities to stay current on best practices within the field of prior authorization services.
- Contributed to a positive work environment by effectively communicating with team members and fostering collaboration.
- Delivered consistent high-quality work under pressure, effectively managing high caseloads while meeting deadlines set forth by payers or internal guidelines.
- Resolved patient billing inquiries and other issues efficiently.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Triaged unscheduled and emergency authorizations, directing submissions to appropriate personnel for rapid response.
- Demonstrated adaptability by managing multiple priorities simultaneously, ensuring all tasks were completed accurately and on time.
- Maintained patient confidentiality and safeguarded medical records to avoid information breaches.
- Achieved high customer satisfaction ratings by providing timely updates to patients and healthcare providers on the status of their requests.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Developed and maintained productive working relationships with healthcare providers.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Communicated with executives about consistent customer issues.
- Read incoming correspondence to ascertain nature of writers' concerns and to determine disposition of correspondence.
- Edited letters and written material for correspondence.
- Presented clear and concise explanations of governing rules and regulations.
- Gathered records pertinent to specific problems, reviewed for completeness and accuracy and attached records to correspondence as necessary.
