Nancy Prieto
UR Specialist
Pompano Beach,FL
Summary
Seasoned professional offering proven clinical knowledge, natural interpersonal strengths and technical abilities. Knowledgeable about EMR charting and interdisciplinary collaboration focused on optimizing patient care and support. Quality-focused and efficiency-driven leader.
Overview
14
14
years of professional experience
Work History
Utilization Review Specialist
Nextus Billing Solutions
09.2019 - Current
- Obtained authorizations from multiple insurance carriers for Mental Health/Substance Abuse levels of care.
- Investigated and resolved insurance issues affecting patient care.
- Performed admission reviews for medical necessity criteria specification.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Conducted ongoing concurrent review with insurance companies, and updated clinical supervisors with current authorization information.
Revenue Cycle Management Specialist
Nextus Billing Solutions
09.2019 - Current
- Effective follow up on outstanding charges via payer web portals, phone and other computerized methods.
- Working through insurance denials and rejection of claims with insurance companies.
- Communicates status of resolution efforts.
- Collections; Posting Charges; Appeals & Denials; Claims; EOBs.
- Effective communication skills, both verbal and written via phone and email.
VOB Specialist /Medical Records Retrieval Specialist
Nextus Billing Solutions
09.2019 - Current
- Able to request and obtain benefit information.
- Evaluate medical records for completion and accuracy.
- Ability to work collaboratively with other Billing professionals.
- Determine insurance eligibility of persons for substance abuse treatment.
- Compile medical records and evaluates accurate information from the facility.
- Knowledge of Assignment and Coordination of benefits.
Customer Service Call Center Representative
Nova Southeastern University
08.2018 - 07.2019
- Efficiently communicate with patients/staff/physicians.
- Accurately process payer information for all department services provided.
- Take incoming calls from patients/provider staff/insurance companies to answer any billing questions and patient account balance information.
- Process patient credit card payments over the phone for patient balance.
- Audit patient accounts.
- Post medical, dental and vision payment from insurance companies and post patient balance per explanation of benefit.
Customer Service Call Center Representative
SOS Group
01.2018 - 07.2018
- Efficiently communicate with patients/staff/physicians.
- Accurately process payer information for all department services provided.
- Take incoming calls from patients/provider staff/insurance companies to answer any billing questions and patient account balance information.
- Process patient credit card payments over the phone for patient balance.
- Audit patient accounts.
- Answer incoming calls and resolve billing issues.
Sortation Division
Amazon
12.2017 - 12.2017
- Able to lift and sort parcels with weight of up to 75 lbs.
- Accurately scan and place parcel on correct pallet for shipment to customer.
- Ability to maintain a scan rate of 130 parcels per hour.
- Sort parcels based on lane letter and ability to quickly separate by numbers for employees to scan and process parcels to pallet for shipment.
- Stack parcels on pallet correctly based on weight for shipment to customer.
- Wrap pallet once full for shipment to be removed to truck for transportation to customer.
Patient Billing /Prior Authorization/Call Center Representative
Quadax
03.2015 - 10.2017
- Efficiently communicate with patients/staff/physicians.
- Accurately process payer information for all department services provided.
- Follow-up with insurance company regarding the processing and payment of claims.
- Correct claims that have missing information per follow-up with insurance company.
- File appeals with insurance company for timely filing or processing disputes.
- Take incoming calls from patients/provider. staff/insurance companies to answer any billing questions and patient account balance information.
- Process patient credit card payments over the phone for patient balance.
- Audit patient accounts
- Process insurance requests via mail/phone for requested information such as doctors progress notes.
- Process insurance /patient refunds requests.
- Post insurance payments.
- Answer incoming calls and resolve billing issues.
- Obtain required prior authorization for required testing from patients insurance company.
Education
Health Information Management
Cuyahoga Community College
Cleveland, OHSkills
- Customer Service Specialist
- Physician/Patient Support Relations
- Computer Medical System(s) Expert
- Medical, Financial Reporting / Administrative Professional
Timeline
Utilization Review Specialist
Nextus Billing Solutions
09.2019 - Current
Revenue Cycle Management Specialist
Nextus Billing Solutions
09.2019 - Current
VOB Specialist /Medical Records Retrieval Specialist
Nextus Billing Solutions
09.2019 - Current
Customer Service Call Center Representative
Nova Southeastern University
08.2018 - 07.2019
Customer Service Call Center Representative
SOS Group
01.2018 - 07.2018
Sortation Division
Amazon
12.2017 - 12.2017
Patient Billing /Prior Authorization/Call Center Representative
Quadax
03.2015 - 10.2017
Health Information Management
Cuyahoga Community College
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