Helen McCrossin
Presque Isle,ME
Summary
Medical Referral Specialist with extensive experience at NL AR Gould Hospital, adept at streamlining prior authorization processes and enhancing provider relations. Proven track record in achieving high approval rates through effective communication and critical thinking. Skilled in medical terminology and committed to delivering exceptional customer service while ensuring compliance with HIPAA regulations.
Overview
4
4
years of professional experience
Work History
MEDICAL REFERRAL/Prior Authorization Specialist
NL AR Gould Hospital
06.2021 - Current
- Assisted in gathering necessary documentation for prior authorization requests.
- Processed incoming requests for medical services and treatments efficiently.
- Communicated with healthcare providers to clarify authorization requirements.
- Maintained accurate records of authorization requests and outcomes.
- Provided support in navigating insurance company guidelines and protocols.
- Developed understanding of medical terminology relevant to authorization processes.
- Collaborated with team members to streamline workflow processes for efficiency.
- Adapted quickly to software systems used in processing prior authorizations.
- Collaborated with physicians to obtain necessary clinical information for prior authorization submissions.
- Maintained thorough knowledge of insurance plan requirements, facilitating accurate and timely completion of authorization forms.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
- Achieved high success rate in obtaining authorizations by effectively demonstrating medical necessity through comprehensive documentation and clear communication with insurance companies.
- Provided training to new staff members on the intricacies of various insurance plans and their specific prior authorization requirements.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Tracked referral submission during facilitation of prior authorization issuance.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Managed a high volume of incoming calls, maintaining professionalism while effectively addressing the needs of callers seeking assistance with prior authorizations.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Maintained organized records and up-to-date files for all completed and pending authorization requests, ensuring easy access during audits or reviews.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Contributed to a high level of customer service by quickly addressing questions or concerns from patients regarding their coverage or denials.
- Coordinated with billing department to resolve discrepancies related to denied claims due to incomplete or incorrect prior authorizations.
- Supported team members by providing guidance on complex cases requiring detailed understanding of medical necessity criteria.
- Enhanced communication between healthcare providers and insurance companies, ensuring prompt resolution of issues related to prior authorizations.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Continually updated knowledge on industry developments, ensuring adherence to best practices and relevant regulatory changes impacting the prior authorization process.
- Improved patient satisfaction with timely and accurate processing of prior authorizations for medications and procedures.
- Developed and maintained productive working relationships with healthcare providers.
- Identified trends in denials through data analysis, adapting strategies accordingly for improved success rates in obtaining approvals.
- Streamlined prior authorization processes by implementing efficient tracking systems.
- Improved provider satisfaction with timely communications regarding authorization status updates.
- Implemented tracking system for prior authorization requests to monitor progress and identify bottlenecks.
- Fostered positive relationships with healthcare providers by ensuring transparent communication throughout authorization process.
- Enhanced efficiency in processing prior authorization requests by streamlining documentation procedures.
- Increased approval rates for necessary medical procedures by providing detailed justifications and patient history during review process.
- Advocated for patients by negotiating with insurance providers to cover necessary treatments not initially authorized.
- Streamlined submission of prior authorization requests, leading to faster patient access to needed treatments.
- Maintained up-to-date knowledge of changing healthcare regulations and insurance policies to ensure accurate processing of requests.
Education
Associate of Science - Medical / Legal Office Admin. / Transcription
Northern Maine Community College
Presque Isle, ME05-2007
High School Diploma -
Washburn District High School
Washburn, ME06-1990
Skills
- Prior authorization process
- Medical terminology
- Medical appeals handling
- Authorizations
- Insurance verification
- Patient referrals
- Electronic health records proficiency
- Medical terminology knowledge
- Physician order verification
- Benefit coverage
- Medical office procedures
- Professionalism and ethics
- Insurance procedures
- Workflow management
- Retro-authorizations
- Patient confidentiality compliance
- Provider relations
- Critical thinking
- HIPAA compliance
- Outpatient surgery coding
- Precertification requirements
- Practitioner order verification
- Eligibility determination
- Referral coordination
- Problem-solving
- Multitasking
- Telephone etiquette
- Appointment scheduling
- Teamwork and collaboration
- Customer service
- Time management
- Reliability
- Excellent communication
- Active listening
- Adaptability and flexibility
- Computer proficiency
- Self motivation
- Professionalism
- Continuous improvement
Accomplishments
- Medical Office Coordinator at NMMC Medical Clinic
- Medical Office Coordinator at Cary Medical Center Radiology
- Over 10 years experience w/medical transcription
- Coordinated multiple medical specialties/modalities appointments/referrals/authorizations simultaneously
- Promote and maintain excellent working relationships with my peers/superiors
- Used Microsoft Excel to develop appointment/referral/authorization tracking spreadsheets.
Languages
English
Native or Bilingual
Timeline
MEDICAL REFERRAL/Prior Authorization Specialist
NL AR Gould Hospital
06.2021 - Current
Associate of Science - Medical / Legal Office Admin. / Transcription
Northern Maine Community College
High School Diploma -
Washburn District High School
Similar Profiles
MEGAN CLARKMEGAN CLARK
Psychiatric Mental Health Nurse Practitioner at Northern Light AR Gould HospitalPsychiatric Mental Health Nurse Practitioner at Northern Light AR Gould Hospital
Victoria KazoroskiVictoria Kazoroski
Certified Ophthalmic Assistant at Northern Light AR GouldCertified Ophthalmic Assistant at Northern Light AR Gould
Kailey McKenneyKailey McKenney
Medical Assistant at Northern Light AR GouldMedical Assistant at Northern Light AR Gould
Carter JacksonCarter Jackson
Fabrication Welder at Soderberg ConstructionFabrication Welder at Soderberg Construction
Codie HendersonCodie Henderson
Home Support Worker at Private HomeHome Support Worker at Private Home