Referral Coordinator and Prior Authorization Specialist
Reno,Nevada
Summary
Referral and Prior Authorization Coordinator with extensive experience in insurance verification and appeals at East Asheville Family Health Care. Utilizes nursing background to effectively advocate for patients during the authorization process. I possess strong skills in coordinating patient care, authorizing procedures, and managing health records. Skilled in ICD-10 coding and patient education, demonstrating strong problem-solving abilities and collaboration in addressing denied authorizations. Highly organized with a proven ability to manage and optimize patient referrals while ensuring compliance with HIPAA standards. Strong work ethic, adaptability, and time management abilities.
Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
Able to utilize my nursing knowledge to coordinate resolutions for denied authorizations in the appeals process and to ensure the patient's understanding of what the provider has ordered.
Utilized both eClinicalWorks and Athena EHR systems.
Evaluated patient eligibility and benefits for requested procedures and medications. Assisted the patient in obtaining costly medication(s) through the patient assistance program.
Maintained a professional attitude when interacting with external customers, such as physicians' offices, drug representatives, or insurance companies.
Trained MA staff on the referral, prior authorization procedures, and company policies.
Trained new staff in the front desk procedures and protocols.
Negotiated with drug manufacturers and insurance providers to obtain coverage for off-label or non-formulary medications.
Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
Verified insurance eligibility for referred services using online databases and contacted insurers directly when needed.
Identified discrepancies in submitted documents or coding errors that may affect payment or reimbursement.
Analyzed denied claims in order to identify potential issues that could be addressed proactively.
Scheduled patient appointments, diagnostic specialty appointments, tests and procedures.
Followed up on both pending referrals and prior authorization requests to ensure timely processing.
. I worked closely with our drug representatives, both in the office and then remotely, after I relocated to Reno.
Referral Specialist
Pinnacle Medical Group
Reno, NV
01.2024 - 03.2025
Utilized the eClinical Works EHR system.
Ensuring that referrals are appropriately authorized by insurance providers.
Maintaining accurate and comprehensive documentation of all referrals, and related communications.
Transmitted medical records and correspondence via mail, email, or fax to ensure timely communication.
Communicating with insurance companies to verify coverage and to obtain necessary authorizations.
Able to utilize my nursing knowledge to coordinate resolutions for denied authorizations in the appeals process and to ensure the patient's understanding of what the provider has ordered.
Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
Utilized medical coding knowledge to accurately process and document authorization requests' ensuring ICD10 and CPT coding was correct
Collaborated with internal staff members to resolve discrepancies or issues related to referrals and prior authorizations. I met weekly with my supervisor and fellow team members to discuss issues. Often, especially with mental health specialists, insurance panels fill up, and the referral needs to be redirected to another office.
Staff Nurse
MAHEC Women's Health Center
Asheville, NC
08.2000 - 10.2008
I was the primary nurse for our urogynecologist. I performed biofeedback, assisted him in urodynamics, and scheduled all his surgeries. I also assisted the physicians in our high-risk maternal-fetal medicine clinic.
Performed diagnostic tests such as blood draws, urine analysis, biofeedback, NSTs, telephone, and acute triage.
Utilized a paper and electronic medical record system to store patient information securely.
Provided direct patient care, including post-C-section wound care, post-bladder/rectal repair, i.e., staple removal, and packing.
Managed multiple tasks simultaneously while maintaining quality standards of care.
Developed individualized teaching strategies for each patient based on their specific needs.
Demonstrated effective communication skills while interacting with patients, families, physicians and other healthcare staff members.
Answered patient questions and provided take-home materials for further information.
Participated in quality improvement initiatives to enhance patient care outcomes.
Prepared medical equipment and tools to aid physician during examination and treatment of patients.
Conducted specified laboratory tests to help detect conditions and determine diagnosis.
Addressed rapid response and code situations by strategically organizing and delegating tasks. I.e., directing EMS to the patient room, calling the report to the ER, and/or Labor and Delivery.
Staff Nurse
MAHEC/Regional
Asheville, NC
08.1996 - 08.2000
Answered incoming calls from patients seeking medical advice or assistance.
Identified symptoms and recommended treatments or follow-up care based on established protocols and guidelines.
Managed multiple tasks simultaneously while maintaining quality standards of care.
Utilized the computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system, eClinical Works.
Achieved departmental goals and objectives by instituting new processes and standards. Assisting in the writing of protocols specific to our practice.
Referred patients to specialized health resources or community agencies to furnish additional assistance.
Demonstrated effective communication skills while interacting with patients, families, physicians and other healthcare staff members.
Mentorship and training preceptor.
Conducted patient education on medical treatments and procedures.
Actively participated in departmental meetings, training sessions and educational seminars.
Maintained updated knowledge through continuing education and advanced training.
Education
Bachelor of Science - Nursing
South College, Asheville
Asheville
06-2019
Licensed Practical Nurse - Practical Nursing
Clevland Community College
Shelby
08-1991
Associate of Science - Prerequisites for nursing
Mars Hill University
Mars Hill
01-1989
Mountain Heritage High School
Burnsville, NC
06-1988
Skills
Prior authorization and precertification processes
Insurance verification and regulatory compliance
Patient education and effective communication
Problem solving and task prioritization
Collaboration and teamwork skills
Documentation accuracy and quality assurance
Healthcare regulations and HIPAA compliance
Medical terminology proficiency
Professional demeanor and adaptability
Trained in eClinicalWorks and Athena EHR systems
Referral management
Appeals coordination
ICD-10 coding
Utilization review experience
Critical thinking
Affiliations
Dog and horse lover. I balance my work and personal life with horseback riding, volunteer work, and being outdoors. Working with horses allows me to reset and decompress, especially if day has been stressful. My dog loves our walks and neighborhood activities.
Custom
In December of 2023 I relocated from Western NC to here in Reno for my new job at Pinnacle Medical Group. In mid September 2024 I started remote work for my previous employer, East Asheville Family Health Care, to assist office in PA's and referrals as they transitioned to a new EHR, also the nurse that had taken over my position left unexpectedly. During this time they were hit with Hurricane Helene.That area was completely devastated and the office was without power, water , phone and internet system. Because I was here working remote, I was able to check on patients; find out where they were displaced,any immediate health issues, call in med refills, and coordinate with their local officials to assist in emergency efforts. I had kept my home there to AirBnb, but sadly it also washed away and my community along highway 19 E in Burnsville, NC was nearly wiped off the map. While I could not be there in person to help my community, I was still able to help from here. I continued my remote work part time for them until April of 2025 while I trained an in-house person to take over position.
Custom
I stopped working in 2008 through 2016 to care for my immediate family that was going through several devastating health problems all at once. You only get one family and they were my priority.