NAKEISHA DAVIS
Fate,TX
Summary
Hardworking Prior Authorization Specialist with successful background working closely with insurance company representatives to gain preapproval for procedures and testing. Detail-oriented performer with over 10 years of managing documentation. Considered team player with exemplary multitasking skills.
Overview
12
12
years of professional experience
Work History
Prior Authorization Specialist
Vital Care Pharmacy
11.2022 - Current
- Input all patient data regarding claims and prior authorizations into system accurately with over 10 years of experience.
- 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.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Developed and maintained productive working relationships with healthcare providers.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
Benefit Verification Specialist-Lead
AMERISOURCEBERGEN
03.2019 - 10.2022
- Contacted insurance carriers to obtain authorizations, notifications, and pre-certifications
- Coordinated resolutions for issues and appealed denied authorizations
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers
- Explained benefits to plan participants in easy-to-understand terms in order to educate each on available options
- Checked employees' benefits enrollment for accuracy and inputted all data into Script med and CPR +
- Resolved issues and inquiries from plan participants regarding health and welfare benefits and deductions through telephone, email and in-person interactions
- Trained new team members in policies and procedures and offered insight into best ways to manage job tasks and duties
- Assured timely verification of insurance benefits prior to patient procedures or appointments
- Made contact with insurance carriers to discuss policies and individual patient benefits
- Maintained strong knowledge of basic medical terminology to better understand services and procedures
- Observed strict procedures to protect sensitive patient information, medical records and payment data
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt
- Reviewed 500 patient cases per week and verified insurance coverage information
- Determined appropriateness of payers to protect organization and minimize risk
- Scheduled patient appointments in respective doctors' calendars and followed up with reminder phone calls
- Registered and verified patient records before triage with most up-to-date information
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
GRIEVANCE& APPEALS SPECIALIST
CIGNA
01.2018 - 11.2019
- Coordinated the intake of appeal and grievances requests from members and providers into the designated systems
- Generated Acknowledgement Letters to mail to appellants and answering general appeal status questions
- Ensuring adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters, and communicating with members and providers within required timeframes
- Prepare case files for Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives
- Investigated and analyzed requirements to improve timeliness of reports to customers
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system
- Checked accuracy and completeness of benefits applications and documents
- Provided detailed information about benefits and limitations of different policies and programs
- Organized paperwork and checked individual pages for accuracy and completeness
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt
- Modified, updated, and processed existing policies
- Coordinated with contracting department to resolve payer issues.
Pharmacy Technician
HUMANA
07.2016 - 12.2018
- Teamed with peers, technicians, and pharmacists to prioritize and complete orders
- Created new customer profile and updated demographics, allergies, and new medications in pharmacy computer systems
- Assisted pharmacist with clearing high volume of prescriptions and responded to customer questions
- Transmitted claims to insurance companies for payment and reconciled
- EOBs
- Prepared prescription transfers to other pharmacies
- Maintained strict patient confidentiality to adhere to HIPAA regulations and avoid data compromises
- Completed and filed patient paperwork, updating records in system with insurance carrier changes and allergy information
- Worked with insurance companies to process claims, resolve problems and obtain payments.
Registrar / Medical Assistant
METHODIST HEALTHCARE
03.2011 - 07.2016
- Answered phone calls to provide assistance, information and medical personnel access
- Scheduled and confirmed patient appointments for diagnostic, surgical and consultation services
- Supervise, train, and provide guidance for the Patient Access team and Registration team
- Oversee patient accounts and entries in Meditech and Epic
- Documented and responded to incoming correspondences to address questions
- Applied knowledge of medical terminology and insurance processes to support office administration productivity
- Managed unit call reception and routed calls to correct department
- Provided patient information to facilitate timely admissions and discharges
- Maintained strong and trusting rapport with patients and all healthcare staff to build relationships
- Monitored unit supply levels and notified management of ordering needs
- Welcome patients and family members in a professional manner providing exemplary customer service
- Transcribed doctors' orders, including medication and lab test requests
- Verify all insurance and obtain pre-certification/authorization.
Education
PHARMACY TECH - Pharmacy
Concorde Career College
Grand Prairie, TXundefined
Everest Career College
Skills
- Understanding of insurance details
- Benefit Coverage
- Authorizations
- EPIC
- Claim research
- Retro-Authorizations
Accomplishments
- Pharmacy Technician
- Medical Assistant
Timeline
Prior Authorization Specialist
Vital Care Pharmacy
11.2022 - Current
Benefit Verification Specialist-Lead
AMERISOURCEBERGEN
03.2019 - 10.2022
GRIEVANCE& APPEALS SPECIALIST
CIGNA
01.2018 - 11.2019
Pharmacy Technician
HUMANA
07.2016 - 12.2018
Registrar / Medical Assistant
METHODIST HEALTHCARE
03.2011 - 07.2016
PHARMACY TECH - Pharmacy
Concorde Career College
undefined
Everest Career College
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