Summary
Overview
Work History
Education
Skills
Experience
Certification
Timeline
Generic

HEATHER GRAHAM

Authorization Specialist
Colorado Springs,CO

Summary

Detail-oriented Healthcare Administrative professional with a 3.9 GPA from Pikes Peak State College and a Medical Billing and Coding degree. Demonstrated expertise in claims analysis, coding, and billing, with hands-on experience as an Authorization Referral Coordinator at United Healthcare and CSR for Federal Employee Blue Dental at Anthem BCBS. Inductee of Phi Theta Kappa Honor Society, showcasing dedication to academic excellence and professional growth. Seeking to use extensive knowledge of private, commercial, and government insurance processes in a challenging healthcare role.

Overview

10
10
years of professional experience
1
1
Certification

Work History

Small Business Owner

Serenity Penguin
Colorado Springs, CO
08.2023 - 01.2025
  • Oversaw operations of small business including customer service and financial management.
  • Managed daily operations, including inventory, vendor relations, and product pricing.
  • Managed company social media and marketing efforts to expand brand awareness and attract new customers.

Authorization Specialist

Human Touch Home Care
Colorado Springs, CO
10.2022 - 07.2023
  • Researched patient eligibility, coverage information, and benefit levels
  • Precertifications and Authorizations for Home Health services supporting 10 office locations
  • Clinical documentation review for Medical Necessity and Medicare Appropriateness.
  • Verified insurance authorizations with payers via telephone or web-based systems.
  • Entered patient data into EMR system with extensive notations of Auth process
  • Prepared Denials, Appeals and Grievance letters on behalf of clients when necessary to resolve disputes with insurers.

Call Center Representative

Randstad Temp Agency
Colorado Springs, CO
08.2018 - 01.2019
  • Provided exemplary support to the Anthem Blue Cross and Blue Shield-Blue Dental Federal Retiree Health Plan operations.
  • Answered incoming calls and provided highest level of professionalism and knowledgeable service to every customer.
  • Examined claims for accurate resolutions, including payouts, denials, and redeterminations.
  • Resolved member and provider queries related to benefits and eligibility.
  • Enhanced member retention by effectively communicating value of Plan Benefits during Open Season.
  • Verified insurance eligibility and benefits.
  • Supported preparation and submission of denials, appeals, and grievances.
  • Contributed to improving digital user experience through efficient website assistance.

Authorization and Referral Coordinator

UnitedHealth Group (Tricare)
Colorado Springs, CO
05.2016 - 11.2018
  • Checking patient eligibility and benefits within the United Healthcare system to confirm coverage for requested services.
  • Assessing the medical necessity of the requested service based on clinical guidelines and plan policies.
  • Accurately inputting patient information, diagnosis codes (ICD), procedure codes (CPT), and other relevant details into the authorization system.
  • Contacting providers to request additional documentation or clarify details regarding the referral.
  • Issuing authorizations for approved services within established timeframes, including urgent or emergent requests.
  • Explaining denial reasons to providers when a referral is not approved and assisting with appeals process if necessary.
  • Government Clearance as a Federal Contracted Employee
  • WAH Status as a top producer in Productivity and Quality
  • Recipient of Monthly Awards and Quarterly Bonus Incentives
  • Head coordinator of the Employee Engagement Committee

Patient Intake and DME Sales

Tens Unlimited
Colorado Springs, CO
04.2015 - 03.2016
  • Coordinated the intake process, ensuring all required documentation was collected and processed.
  • Assisted with new patient registration, verifying insurance information and collecting co-payments.
  • Answered questions related to insurance coverage, eligibility requirements, payment options.
  • Conducted follow-up communication with clients to evaluate satisfaction and outcomes of services provided.
  • Managed electronic health record systems ensuring accuracy of data entry.
  • Facilitated communication between clients, family members, and healthcare providers to ensure seamless product delivery.

Education

Certificate of Technical Studies - Medical Billing and Coding

Pikes Peak State College
Colorado Springs, CO
05-2022

Certificate of Technical Studies - Pharmacy Technician

Simi Institute of Career And Education
Simi Valley, CA
01.2007

High School Diploma -

Santa Susana High School
Simi Valley, CA
01.2003

Skills

  • Medical Front Office Management
  • A/R and A/P Experience
  • Intermediate Microsoft Office
  • Home Health
  • DME
  • Insurance and Benefits Verification
  • Authorization and Referrals
  • Denials and Appeals
  • Claims Review
  • Medical Billing and Coding
  • ICD 9 and ICD 10
  • CPT
  • HCPCS
  • Modifiers
  • Pharmacology
  • Time Management
  • Small Business Operations

Experience

More than 15 year's experience working in customer service in the healthcare industry.

Certification

  • Certified Professional Coder (CPC), American Academy of Professional Coders (AAPC)

Timeline

Small Business Owner

Serenity Penguin
08.2023 - 01.2025

Authorization Specialist

Human Touch Home Care
10.2022 - 07.2023

Call Center Representative

Randstad Temp Agency
08.2018 - 01.2019

Authorization and Referral Coordinator

UnitedHealth Group (Tricare)
05.2016 - 11.2018

Patient Intake and DME Sales

Tens Unlimited
04.2015 - 03.2016

Certificate of Technical Studies - Medical Billing and Coding

Pikes Peak State College

Certificate of Technical Studies - Pharmacy Technician

Simi Institute of Career And Education

High School Diploma -

Santa Susana High School

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HEATHER GRAHAMAuthorization Specialist