Nana Bekauri
Brooklyn,NY
Summary
Detail-oriented Prior Authorization Specialist with 4+ years of experience managing prior authorizations, insurance verification, and payer communications across Medicare, Medicaid, Medicare Advantage, and commercial insurance plans. Experienced in reviewing medical documentation, interpreting payer guidelines, resolving authorization issues, and collaborating with providers to ensure timely, accurate decisions. Proficient in Niko Health, Availity, ePACES, Parachute, and the Noridian Medicare Portal. Seeking to leverage my healthcare operations experience in a health insurance company within Prior Authorization, Medical Management, Utilization Management, or Provider Operations.
Overview
4
4
years of professional experience
Work History
Prior Authorization & Insurance Specialist
City DME
02.2024 - Current
- Managed authorizations for DME across Medicare, Medicaid, and Commercial insurance plans while ensuring compliance with payer guidelines.
- Tracked authorization approvals, denials, and pending cases while maintaining accurate documentation and ensuring timely follow-up with insurance plans.
- Collaborated with intake, billing, providers, and clinical staff to obtain required documentation and facilitate timely authorization decisions.
- Reviewed prescriptions, clinical documentation, and authorization requests to ensure compliance with payer requirements and medical necessity criteria.
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
- Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing online eligibility systems to verify patient coverage and policy limitations.
- Identified reasons for denied claims and collaborated with insurance carriers to resolve issues.
- Documented medical claims and prior authorization requests for processing.
- Monitored changes in insurance policies and guidelines to ensure compliance with prior authorization processes.
- Communicated authorization decisions, including approvals and denials, to healthcare providers and patients.
Prior Authorization Specialist
Family Medical Supply
03.2022 - 12.2023
- Processed prior authorization requests for medical supplies and equipment.
- Verified member eligibility, insurance benefits, and authorization requirements while communicating with payers to facilitate timely approvals.
- Maintained detailed records of authorization approvals and denials to support compliance and operational efficiency.
- Communicated with healthcare providers to gather necessary documentation.
- Reviewed patient information to ensure alignment with insurance guidelines and improve approval rates.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Utilized medical coding knowledge to accurately process and document authorization requests.
- Trained new staff on prior authorization procedures and company policies.
- Entered claims and prior authorizations into the medical records system.
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
Education
BBA - Business Administration
Business And Technology University
Georgia06-2022
Skills
- Authorization Management
- Medicare, Medicaid, Commercial Insurance
- Insurance verification, Eligibility verification
- Medical Documentation Review, Medical Necessity Review
- HCPCS Codes
- ICD-10 Diagnosis Codes
- Denial Resolution
- Provider Relations
- Data entry accuracy
- Detail orientation
- Claims management
- Time management
- Problem solving
- Team collaboration
- Provider relations
- Workflow management
- Payer Policy Compliance
LANGUAGES
English: Native/ Bilingual
Georgian: Native/ Bilingual
Russian: Limited
Timeline
Prior Authorization & Insurance Specialist
City DME
02.2024 - Current
Prior Authorization Specialist
Family Medical Supply
03.2022 - 12.2023
BBA - Business Administration
Business And Technology University