Melissa Martinez - CPhT
Prior Authorization Specialist
Volo,IL
Summary
High-functioning Certified Pharmacy Technician with exceptional communication skills offering patient-centric approach to comprehensive administrative support in healthcare clinics and facilities. Excellent knowledge and skills of 5+ years in Revenue cycle, Insurance verification, Claims Integrity, Benefits, Prior authorization, Appeal/Denials, and Accounts receivable, and Specialty pharmacy. Proficient in managing multiple cases, optimizing patient care. Exceptional organizational skills coupled with strong work ethics aimed at projecting a positive company image. Expert in delivering consistent customer service to ensure client satisfaction and service improvement. Organized and successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
9
9
years of professional experience
1
1
Certification
1
1
License
Work History
Patient Services Specialist
AmerisourceBergen
04.2023 - Current
- Perform patient onboarding, investigate benefits, prior authorizations, process appeals and denials on behalf of patients and their physician to facilitate the process between the doctor's office and pharmacy.
- Provide above services for a health system’s ambulatory and specialty pharmacy.
- Verified benefits for both medical coverage and pharmacy.
- Utilize the health system’s EMR system mainly in Epic and Indicare and other applicable systems to retrieve information needed to deliver services, communicate status and document outcomes.
- Established relationships with assigned clinic staff, pharmacy and hospital contacts, and keep them informed of patients' status and payer challenges.
- Interact with patients and providers to obtain insurance and patient information needed to request prior authorizations for services rendered are reimbursed by payer.
- Initiate prior authorization through electronic portal, Cover My Meds portal, and or verbally.
- Verified and updated ICD 9,10, and CPT codes.
- Understand and follow URAC and CMS strict guidelines and regulations.
- Process prior authorizations for Medicaid through State website and or phone system.
- Strong knowledge of various payers and understanding of prior authorizations and appeals process.
- Facilitate patient enrollment into manufacturer and or foundation sponsored patient assistance programs.
- Able to demonstrate flexibility, and adaptability to changes in payer, pharmacy, and patient assistance program processes and requirements.
- Reviewed and verified customer information and insurance provider information.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Analyzed medical records, referrals, and claims to determine approval of requests for authorization.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Developed and maintained productive working relationships with healthcare providers.
- Tracked referral submission during facilitation of prior authorization issuance.
- Performs additional related duties as assigned.
Claims Integrity Specialist II
IRhythm Technologies Inc.
12.2020 - 03.2023
- Verified patient demographics, insurance and that all other registration information is accurate by submitting email, phone, and fax inquiries.
- Demonstrated timely customer service and cross-functional coordination of account information to promote and maintain positive customer service.
- Perform completion of claims to payers.
- Verified claim is coded in a way that is applicable to the diagnosis.
- Filed and maintained patient records in accordance to HIPAA regulations.
- Resubmitted claims with updated information and made sure claims were paid from responsible party in a timely fashion and accordance with health plan policies.
- Researched CPT and ICD-9 and 10 coding discrepancies for compliance and reimbursement accuracy.
- Examined patients' insurance coverage, deductibles, insurance carrier payments and remaining balances not covered under policies when applicable.
- Followed up with customers on unresolved billing issues.
- Work on special projects for the Accounts Receivable department utilizing Xifin.
- Some of the responsibilities included: researching aged modified unpaid insurance claims and coding discrepancies.
- Resubmit denied authorization request by appealing and determining reason for denial.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Always open to work other tasks delegated by the supervisor.
Patient Financial Navigator
IRhythm Technologies Inc.
11.2019 - 12.2020
- Handle high volume inbound call center.
- Verified insurance coverage by phone and online to ensure proper coordination reimbursement of benefits and estimates of patients' financial responsibilities of commercial, governmental, and third-party insurances.
- Educated patients regarding insurance benefits and available resources.
- Communicated between patients and insurance companies for patients understanding and knowledge of insurance coverage.
- Implemented a plan of action for patients in need of financial assistance.
- Input customer insurance information into the computer system utilizing Salesforce.
- Provided excellent customer service to patients and medical staff.
- Facilitated communication between patients and various departments and staff.
- Responded to inquiries by directing calls to appropriate personnel.
- Helped address client complaints through timely corrective actions and appropriate referrals.
- Verified patient insurance eligibility and entered patient information into system.
Patient Advocate Specialist
Orsini Speciality Pharmacy
11.2018 - 11.2019
- Set up and arrange deliveries for rare specialty drugs for patients/and doctor office.
- Handle high volume incoming calls and outbound calls.
- Verify patient benefits via online portal.
- Enter payment source and collect payments through secured portal.
- Report all adverse events to pharmacist and document all activities in company system.
- Handled escalations, PAP assistance, claim rejection, prior authorizations, and other limitless issues.
- Properly schedule and perform follow-up adherence calls to ensure success and compliance with medication.
- Provide training for new hires.
- Resolved customer complaints.
- Compiled and maintained patient medical records to keep information complete and up-to-date.
- Worked effectively in fast-paced environments.
Patient Service Representative II
Option Care
03.2016 - 04.2018
- Managed patient caseloads for medication compliance and coordination of supplies utilizing CPR+ software and Docutrack
- Maintain patient inventory of medical solutions, level of supplies and monitor usage weekly
- Identified potential issues in regards of inventory or delivery and initiated actions to resolve them
- Scheduled deliveries and pickups of equipment and supplies
- Generate delivery tickets
- Collaborate with warehouse to arrange delivery/pickup
- Filed and maintained patient records in accordance with HIPAA regulations
- Built and maintained positive working relationships with patients and staff
- Managed patient registration process, confirming data accuracy and completeness
- Responded to inquiries by directing calls to appropriate personnel
- Engaged with patients to provide critical information
- Taught patients and families to use at-home medical equipment
Data Entry Pharmacy Technician
PharMerica
11.2014 - 03.2016
- Enter data to fill prescriptions and to obtain reimbursement/payment utilizing AS-500 system.
- Produced reports and kept management informed of unpaid claims and claims pending follow-up.
- Perform computer system operations; which included order entry, billing, crediting, and updating medical records.
- Calculated dosage, filled prescriptions, and prepared prescription labels with absolute accuracy.
- Answered incoming phone calls and addressed questions from customers and healthcare providers.
- Performed various pharmacy operational activities with strong commitment to accuracy, efficiency, and service quality.
- Counted and labeled prescriptions with correct item and quantity.
- Maintained proper drug storage procedures, registries, and records for controlled drugs.
Education
Bachelor Of Applied Science - Health Service Administration
Colorado Technical University
Colorado Springs, CO2013
Associate Of Science - Medical Assistant
Robert Morris University - Illinois
Chicago, IL08.2009
Skills
- Time management
- Problem-solving
- Analytical
- Interpersonal
- Flexibility/adaptability
- Teamwork
- Multitasking
- Attention to detail
- Ability to work independently
- Patient Confidentiality
- Problem-Solving Skills
- Strategic Thinking
- Active Listening
- Customer Experience
- Medicare and Medicaid Processes
- Professional Relationships
- Customer Interaction
- FDA and HIPAA Compliance
- Medication Therapy Management
- Customer Account Management
- Diagnostic Codes
- Benefit Coverage
- Insurance Procedures
- Electronic Health Records Systems
- Data Entry
- Authorizations
- Benefits Verifications
- Explaining Patient Benefits
- Accounts Payable
Certification
- CPhT - Certified Pharmacy Technician
- Licensed Pharmacy Technician of Illinois
Timeline
Patient Services Specialist
AmerisourceBergen
04.2023 - Current
Claims Integrity Specialist II
IRhythm Technologies Inc.
12.2020 - 03.2023
Patient Financial Navigator
IRhythm Technologies Inc.
11.2019 - 12.2020
Patient Advocate Specialist
Orsini Speciality Pharmacy
11.2018 - 11.2019
Patient Service Representative II
Option Care
03.2016 - 04.2018
Data Entry Pharmacy Technician
PharMerica
11.2014 - 03.2016
Bachelor Of Applied Science - Health Service Administration
Colorado Technical University
Associate Of Science - Medical Assistant
Robert Morris University - Illinois
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