Erica Rodriguez
San Antonio,TX
Summary
Hardworking Prior Authorization Specialist with successful background working closely with workers compensation, private commercial and medicare insurance company representatives to gain prior approval for procedures and knowledgeable in regulatory standards and compliance requirements per insurance guidelines. Also, a 16 year background spent working in medical offices, communicating effectively orally and through writing and developing prior authorization workflows. Considered team player with exemplary multitasking skills.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Authorization Specialist
Sleep Therapy And Research Center
12.2022 - Current
- Verified eligibility and compliance with authorization requirements for 8 service providers who saw 15-20 patients daily.
- Tracked referral submission during facilitation of prior authorization issuance.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures. for approximately 20-30 patients daily
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Also, notifies supervisor of known or potential insurance coverage or referral issues
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Obtain authorization if needed from insurance company for medication authorization and patient responsibility
- Input all patient data regarding claims and prior authorizations into system accurately.
- Contacted clients about concerns and answered questions and resolved concerns to uphold exceptional customer service standards
- Motivated and encouraged staff to enhance productivity and meet demanding internal and customer targets.
- Processed patients lacking coverage for planned procedures.
Scheduler
Baptist Health
09.2022 - 12.2022
- Generated department orders and accompanying documentation.
- Worked with supervisors and team members to understand supply needs and bring levels within desired tolerances.
- Upheld HIPAA regulations and standards for protecting patient information.
- Coded and abstracted medical records according to ICD-10-CM and CPT coding guidelines.
- Skilled at working independently and collaboratively in team environment.
- Proven ability to learn quickly and adapt to new situations.
- Used provided call list to sort, organize and prioritize before making outbound calls to potential customers.
- Acted as first point of contact and set appointments for 70-80 prospective clients.
Precertification Specialist
The Start Center for Cancer Care
08.2021 - 09.2022
- Responsible for verifying insurance including but not limited to obtaining complete and accurate insurance information, accurately interpreting benefits and investigating details
- Also, notifies supervisor/ financial counselor of known or potential insurance coverage or referral issues
- Ensure all prior authorization for radiation treatment chemotherapy treatments are obtained prior to delivery of services for tracking, obtaining and extending authorizations from various insurance companies in timely manner, requesting input from appropriate team members as needed
- Enter all data obtained
- Investigate why claim is being denied and provide accurate information to reprocess claim to insurance AR representative
- Pre Certification Specialists
- Answered phone calls and messages for 8-physician oncology medical facility, scheduling appointments, and handling patient inquiries
Patient Service Representative
Urology San Antonio
06.2020 - 07.2021
- Responsible for verifying insurance eligibility and coverage for patients. including but not limited to obtaining complete and accurate insurance information, accurately interpreting benefits and investigating details for vasectomies, diagnostics, medication, and radiation benefits
- Promptly notified correct point of contact if financial or potential insurance coverage or referral issues
- Provided exceptional customer service to patients, answering questions and addressing concerns.
- Ensure all prior authorization for radiation consultation is obtained prior to delivery of services also for space oar and assist in chemo drugs and radiation treatment. Then notify clinical staff of authorization
- . Maintain organized process for tracking, obtaining and extending authorizations from various insurance companies in timely manner, requesting input from appropriate team members as needed
Point of Service Representative
The Start Center for Cancer Care
07.2019 - 05.2020
- Responsible for verifying insurance including but not limited to obtaining complete and accurate insurance information, accurately interpreting benefits and investigating details
- Accepted payments and updated accounts with latest information.
- Also, notifies supervisor/ financial counselor of known or potential insurance coverage or referral issues
- Ensure all prior authorization for radiation treatment is obtained prior to the delivery of services for tracking, obtaining and extending authorizations from various insurance companies in a timely manner, requesting input from appropriate team members as needed
- Handled customer inquiries and suggestions courteously and professionally.
- Clarified customer issues and determined root cause of problems to resolve product or service complaints.
- Also, performs other duties as assigned.
Patient Service Representative
Texas Oncology
05.2017 - 06.2019
- Responsible for verifying insurance including but not limited to obtaining complete and accurate insurance information, accurately interpreting benefits and investigating details
- Also, notifies supervisor/ financial counselor of known or potential insurance coverage or referral issues
- Ensure all prior authorization for referral to provide services is obtained prior to the delivery of services for tracking, obtaining and extending authorizations from various primary physicians and insurance companies in a timely manner, requesting input from appropriate team members as needed
- Enter all data obtained
- Investigate why a claim is being denied and provide the accurate information to reprocess the claim to insurance AR representative
- Prepares daily clinic schedule and enters in all scheduled patients and add-ons
- Also, performs other duties as assigned.
Patient Service Representative II
Nueva Vida Behavioral Health Associates, Inc
08.2008 - 06.2017
- Collect co-payments; work the front desk with duties of greeting clients, handing out intake paperwork; and scanning necessary documentation/information (i.e., insurance cards and driver licenses)
- Run monthly caseload queries for therapist and update data from staffing
- Responsible for verifying insurance including to verify appropriate CPT for workers compensation and obtaining complete and accurate insurance information, accurately interpreting benefits and investigating details
- Also, notifies supervisor of known or potential insurance coverage issues
- Ensure all prior authorization for services is obtained prior to the delivery of services for tracking, obtaining and extending authorizations from various carriers in a timely manner, requesting input from appropriate team members as needed
- Appeals for additional services (extended stays, visits, authorization extension, letter of medical necessity) and refers to additional resources when necessary
- Which include mental health diagnostic interviews, mental health testing, individual counseling and medication management with workers compensation
- Texas Department of Assistive and Rehabilitation Services (TARS) duties include faxing purchase orders with medical services provided to Case Worker and calling on payment collections
- Obtain letter of protection with attorneys offices for mental health services we provide
- Responsible for obtaining the Physician Prescription for evaluation and treatment prior to initial evaluations
- Score Mental Health Testing assessments for our providers which included the following: Minnesota
- Multiphasic Personality Inventory (MMPI), Million Behavioral Medicine Diagnostics (MDM), Battery for
- Health Improvement 2 (BHI-2) and Self Directed Search (SDS)
- Handle all psychological medication referrals scheduling rescheduling and handle medications which includes faxing to pharmacy and check on disputes on denied medications and billing
- As well as handling prior authorization for medication
- Assist clinical director to perform peer to peer calls with the doctors and some nurse case managers on services sent out for prior authorization
Referral Coordinator/Medical Assistant
INJURY ACCIDENT BENEFIT CLINIC
11.2007 - 07.2008
- Handle calls, scheduling, rescheduling and confirming of appointments
- Intake client insurance information which causes for very strong attention to detail
- Pull and prepare charts
- Verify workers compensation insurance benefits
- Obtain letter of protection with attorneys offices for services provided
- Assist with physical therapy and proved excellent patient care.
- Responded to patient inquiries to offer timely updates regarding referral status
- Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process
Education
High school diploma -
Sidney Lanier
06.2003
Skills
- Benefits Verifications
- Referral Tracking
- Procedures Compliance Specialist Procedures
- Prescription Coordination
- Authorizations Knowledge
- Authorizations
- Retro-Authorizations
- Health Insurance Plan Knowledge
- Strategic Initiatives
- Billing Procedures
Certification
Customer Service (10+ years)
Call Center
Front Office (7 years)
Data Entry (10+ years)
Medical Terminology (10+ years)
Intake Experience (10+ years)
Workers' Compensation (7 years)
ICD-10 (5 years)
ICD-9
Insurance Verification (10+ years)
CPT Coding (10+ years)
Medical Scheduling
Timeline
Authorization Specialist
Sleep Therapy And Research Center
12.2022 - Current
Scheduler
Baptist Health
09.2022 - 12.2022
Precertification Specialist
The Start Center for Cancer Care
08.2021 - 09.2022
Patient Service Representative
Urology San Antonio
06.2020 - 07.2021
Point of Service Representative
The Start Center for Cancer Care
07.2019 - 05.2020
Patient Service Representative
Texas Oncology
05.2017 - 06.2019
Patient Service Representative II
Nueva Vida Behavioral Health Associates, Inc
08.2008 - 06.2017
Referral Coordinator/Medical Assistant
INJURY ACCIDENT BENEFIT CLINIC
11.2007 - 07.2008
High school diploma -
Sidney Lanier
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