Natanya Gaston

• Generate daily authorization error report, review, correct, and reconcile to pay claims.
• Provides reporting on authorization issues and trends identified related to claim denials, reconsiderations, and appeals.
• Investigate pended claims for authorization, conduct timely review of authorization module and reconcile for claim payment.
• Identify and process retrospective authorizations for services not requiring medical review.
• Identifies claim issues related to authorization that impact the resolution of claims and escalates as appropriate.
• Researches health plan providers and policies to identify preferred in-network providers and requirements for referral authorization; provides supporting documentation to health plan.
• Remains up to date on Healthcare, authorization processes, policies and procedures.
• Perform outreach, researches and resolves all open or pending authorization issues that impact claim denials, reconsiderations, or appeals.
• Strong knowledge of medical terminology and insurance.
• Performs other duties as assigned.
• Complies with all policies and standards.
• Act as a subject matter expert to other team members for the overall authorization process and for multiple service types at different levels of urgency.
• Ensures all assigned authorization issues and/or errors are resolved within the appropriate time frame to avoid interference with the processing of claims.

· Initiate authorization requests for Home Health and Durable Medical Equipment request.

· Screen for eligibility and benefits. Screen members by priority for case management (CM) assessment. Perform transition of care duties to include but not limited to, contact the member’s attending physician, member or medical power of attorney, other medical providers (home health agencies, equipment vendors) for information pertaining to special needs.

· Collaborate with various business units to resolve claims issues and provide instruction to providers’ billing staff and services regarding claims submission policies and procedures to ensure prompt and accurate claims adjudication. Direct and educate DME vendors and Home Health agencies with the authorization submission process.

· Mail notification of approval letters to members.

· Confirm clinical notes are attached to ordering physician request if not an outreach is made via phone or fax to assure the request is processed in a timely manner.

· Train new hires on system and usage. Guide staff regarding benefits, authorization requirements and policy and procedure.

· Steer non par provider request to a par provider for service.

· Process Referral request for members that are being discharged from an inpatient setting. Contact Facility Discharge Planner in order to obtain the order. Search is conducted using member’s location for a DME vendor or Home Health company that is able to service the member in a timely manner. Request is created and tasked to Urgent nurse for processing.

● Create authorization request for Outpatient, Inpatient, LTAC, DME, Home Health Care, Transportation, Genetic Testing and Rehabilitation services accordance with the prior authorization list. Route to appropriate staff when needed.

● Generate approval letters to providers and facilities.

● Verify provider affiliation to plan and requirement for procedure codes.

● Data enters authorization into the system.

● Review and attach medical records to authorization and task to nurse reviewer for processing.

● Answer phone queues and process faxes within established standards

● Reviewed and adjudicated professional claims not limited to HMO, PPO, POS, Medicare and Medicaid.

● Interpret and apply all applicable guidelines/regulations implemented by CMS, NY State and other entities processing policies and procedures.

● Research and reviewed sensitive correspondence and/or letters written to the Senior Management Team by Providers, Physicians, Department of Insurance, Collection Agencies and other external entities.

● Evaluate and finalize all edits in a timely processing manner according to Medicare guidelines.

● Initiate system generated form letters for medical records or claim denial.

● Analyze patient medical information to identify whether investigation for coordination of benefits, subrogation, worker’s compensation or no fault is necessary and to be encountered.

● Utilize knowledge of ICD-9, ICD-10, CPT, HCPCS codes, POS and TOS to render accurate claims decision.

● Responding to inbound inquiries pertaining to benefits eligibility, benefits explanations, claims information and appeals process and procedures.

● Responsible for effectively following up on inquiries through investigations with other entities including internal department and providers.

● Assist clients with billing concerns and discrepancies.

● CMS compliance and accurate documentation.

● Proficient in meeting deadlines and working in a team environment.

● Assist provider and member with pharmacy benefits and eligibility.

● Resolve concerns and grievances related to prescription and medical coverage.

● Assist members with inquires related to the pharmacy formulary process.