MELISA RAMIREZ
Rosenberg,TX
Summary
Healthcare professional with over 20 years of experience in enhancing organizational initiatives through effective communication, negotiation, and persuasion. Expertise in managed care, Medicare, Medicaid, and commercial insurance, along with proficiency in medical terminology and ICD-10 coding. Proven ability to collaborate with cross-functional teams and drive results. Committed to leveraging skills and experience to contribute to organizational success.
Overview
14
14
years of professional experience
Work History
Authorization Specialist
Talis Healthcare
Remote, TX
12.2024 - Current
- Oversee re-authorizations for 20+ clinics
- Collaborate with registered nurses to uphold compliance and enhance operational efficiency.
- Utilize authorization report to maintain precise spreadsheets for upcoming re-authorizations.
- Review medical documentation for compliance with insurance guidelines.
- Manage electronic medical records using advanced healthcare software systems.
- Resolve discrepancies in patient information to ensure accurate processing.
- Track authorization statuses using electronic databases or manual filing systems.
- Perform data entry into various computer systems including but not limited to EMRs and CRMs.
- Verify insurance authorizations with payers via telephone or web-based systems.
- Review authorization requests for accuracy and completeness.
Prior Authorization Specialist
DeliverIt Pharmacy Infusion and Specialty
Sugar Land, TX
08.2021 - 12.2024
- Knowledge of obtaining electronic, verbal and written authorizations from various health insurance companies for medication and infusion therapies prescribed
- Communicate effectively with the doctor's office to obtain necessary clinical information for authorization submission
- Knowledge of prior authorization requirements for various treatments
- Thorough understanding of treatment protocols of the specified specialty, procedures and diagnosis which require an authorization
- Knowledge of HCPCS and CPT codes
- Ability to calculate quantity units needed for each requested code for authorization processing
- Ensure units and dates of service are sufficient for duration of authorization
- Work with insurance plans to resolve any discrepancies or issues on prior authorizations submission or approvals.
- Assist doctor offices with submission of PA appeals as needed
- Track and follow each authorization from monthly appointment calendar to efficiently meet all prior authorization deadlines before patient's scheduled appointment or next dosing
- Ability to verify patient's insurance coverage and eligibility by phone or insurance platforms
- Communicate with the doctor office and patients regarding insurance coverage and benefits.
- Update patient demographics and insurance information as needed
- Daily interaction with other departments to assist patients and providers with problems or questions and act as a facilitator to resolve questions or concerns
Admissions Coordinator
Cambridge Health And Rehabilitation Center
Richmond, TX
02.2012 - 08.2021
- Work closely with case managers, physicians and families to ensure appropriate placement for patients
- Maintain communication with hospital discharge personnel, administrators, other nursing homes, physicians, rehabilitation centers and home care agencies
- Coordinate with medical, nursing and accounting staff to ensure smooth transition for patient admission
- Complete admission paper work with families and/or patients and make bed assignments
- Conduct tours and phone inquiries and follow up with patients/families upon admission and discharge
- Remain up-to-date with all insurance requirements, including the details of patient financial responsibilities
- Efficiently perform insurance pre-authorizations and remain the primary contact for insurance personnel for updates
- Demonstrate knowledge of HIPAA Privacy Regulations by appropriately handling patient information
Education
Associate of Applied Science - Health Information Technology
Wharton County Junior College
Wharton, TX05.1995
Associate of Applied Science - Computer Operations
Wharton County Junior College
Wharton, TX05.1992
Skills
- Knowledge of Managed Care
- Medicare/Medicaid
- Commercial Insurance Payors
- Proficient in medical terminology
- ICD-10 coding
- Microsoft Office
- MS Excel
- MS Word
- MS Teams
- MS Outlook
- Caretend
- WeInfuse
- Insurance Verification
- Authorization submission via phone/portal
- Multitasking
- Teamwork and collaboration
- Fax technology
- HIPAA compliance
- Excellent customer service skills
- Excellent verbal/written communication
- Detail oriented
References
References available upon request.
Timeline
Authorization Specialist
Talis Healthcare
12.2024 - Current
Prior Authorization Specialist
DeliverIt Pharmacy Infusion and Specialty
08.2021 - 12.2024
Admissions Coordinator
Cambridge Health And Rehabilitation Center
02.2012 - 08.2021
Associate of Applied Science - Health Information Technology
Wharton County Junior College
Associate of Applied Science - Computer Operations
Wharton County Junior College
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