Nathaniel Capo-Deimling
Elyria
Summary
Efficient, detailed Prior Authorization Rep bringing about a little over 1.5 years of excellent experience spanning in the healthcare industry in related roles. I excel in a fast-paced environment while being well organized, reliable, and dependable. I possess great interpersonal, teamwork, and multitasking skills. I have knowledge of insurance verification, patient care, billing procedures, administrative support, prior authorization, electronic health records, such as Epic, MHK, and PeopleSafe, and patient data entry. I am educated in HIPAA compliance and following policies and procedures. I am self-motivated and always ensure my tasks are completed in a timely manner by being good at multitasking.
Overview
5
5
years of professional experience
1
1
Certification
Work History
Prior Authorization Rep
CVS Health/Aetna
09.2024 - Current
- Being interpersonal and answering calls from CARE Agents in other departments, medical doctor offices, and members in clear and kind introductions in order to assist their needs with accuracy.
- Complete Prior Authorizations for medical doctor offices by running a pharmacy test claim and either generating a key for the request to be completed online on CoverMyMeds or completing a case for the rejection.
- Verifying 3 identifiers with attention to accuracy for members like name, date of birth, member ID, phone number, address, or prescriber and insurance verification.
- Make an appealed redetermination case if the coverage determination was denied within 65 days and is the same prior authorization reason.
- Obtaining info on the name of medication, quantity, day supply, requesting provider NPI, priority, and name of the caller, formulary ID, coverage determination, redetermination, or organization determination in special cases if the plan is a MA only plan in order to complete a case making sure to pay attention to detail and multitasking.
- Approve, send requests for more information faxes to doctors offices, or send cases to clinical pharmacists based on a coverage determination or redetermination appeal case and how prior authorization criteria questions, quantity limit questions, quantity opioid 7 day, or non-formulary questions are answered.
- Transfer medical doctor offices or members to the appropriate department while maintaining being kind and courteous if needing assistance or to help a need that is out of the parameter of my job duties. Transfer medical doctor offices or members to the pharmacist based on how clinical questions are answered or on the specific prior authorization rejection.
- Determine prior authorization rejection with accuracy as either a prior authorization is needed, quantity limit, non-formulary medication, not covered under part D, B vs D determination, hospice, step therapy, tiering, or quantity opioid 7 day.
- Report HIPPA violations.
- Dismiss a case if a prescriber is requesting to withdraw the med request.
- Answer any questions that a member or prescriber might have while being kind about the status of a case like approved, denied, in progress, or request for information. Or if a med needs a prior authorization of any kind.
- Being involved and collaborative in weekly/monthly team meetings.
Spec Patient Access
Mercy Health Allen
09.2023 - 09.2024
- Company Overview: (ensemble)
- Register patients in the emergency room, labs, x-rays, ultrasound, cat scan, ekg, using attention to detail and in a timely manner to make sure patients are being seen quickly and all of the information is correct while also obtaining signatures.
- Using attention to detail to check if patients are already scheduled for an appointment and pointing them in the right direction using excellent communication to ensure they get to their appointment in a timely manner.
- Answering code alarms and announcing them to the hospital and helping to direct patients, using leadership and patient service to ensure safety.
- Work together with other departments in the hospital when they have questions, offering administrative support for good teamwork.
- Working on patient charts for the emergency room and walk-in appointments, using medical terminology, medical coding, and dealing with billing while verifying health insurances to take payments to ensure accurate patient information and high-quality care.
- Answering phone calls from other departments in the hospital and from patients to help answer any questions that need to be addressed or to help complete any tasks that need to be completed.
- Putting in procedure and diagnosis codes into patient charts from doctors' orders with accuracy and attention to detail.
- Using Microsoft Excel to create the next day's schedule with accuracy and attention to detail.
- Receiving mail and faxed physician orders.
- (ensemble)
Float Spec Patient Access
Mercy Health Allen
09.2023 - 03.2024
- Register patients in the emergency room, labs, x-rays, ultrasound, cat scan, ekg, using attention to detail and in a timely manner to make sure patients are being seen quickly and all of the information is correct while also obtaining signatures.
- Using attention to detail to check if patients are already scheduled for an appointment and pointing them in the right direction using excellent communication to ensure they get to their appointment in a timely manner.
- Answering code alarms and announcing them to the hospital and helping to direct patients, using leadership and patient service to ensure safety.
- Work together with other departments in the hospital when they have questions, offering administrative support for good teamwork.
- Working on patient charts for the emergency room and walk-in appointments, using medical terminology, medical coding, and dealing with billing while verifying health insurances to take payments to ensure accurate patient information and high-quality care.
- Answering phone calls from other departments in the hospital and from patients to help answer any questions that need to be addressed or to help complete any tasks that need to be completed.
- Putting in procedure and diagnosis codes into patient charts from doctors' orders with accuracy and attention to detail.
- Using Microsoft Excel to create the next day's schedule with accuracy and attention to detail.
- Receiving mail and faxed physician orders.
Retail Support
Macy's
11.2019 - 01.2020
- Received payments by cash, credit cards, or debit cards.
- Issued receipts, refunds, or change due to customers.
- Assisted customers by providing information and resolving their complaints.
- Processed merchandise returns and exchanges.
Education
Healthcare Administration - Healthcare Administration
Western Governors University
Salt Lake City, UT04.2024
Bachelors Of Science - Integrated Health Studies
Kent State University
Kent, OH05.2022
Associate’s - Universal Science
Lorain County Community College
Elyria, OH05.2019
Skills
- Prescription Authorizations
- HIPAA compliance
- Insurance verification
- Medical terminology
- Data entry
- Insurance authorization
- Effective communication
- Critical thinking
- ICD-10 coding
- Teamwork
- Customer service
- Problem-solving
- Time management
- Attention to detail
- Multitasking
- Organizational skills
- Active listening
- Decision-making
- Self motivation
- Interpersonal
- Analytical thinking
- Billing procedures
Certification
BLS Certified, American Heart Association, Cleveland Clinic Foundation (2022)
Timeline
Prior Authorization Rep
CVS Health/Aetna
09.2024 - Current
Spec Patient Access
Mercy Health Allen
09.2023 - 09.2024
Float Spec Patient Access
Mercy Health Allen
09.2023 - 03.2024
Retail Support
Macy's
11.2019 - 01.2020
Healthcare Administration - Healthcare Administration
Western Governors University
Bachelors Of Science - Integrated Health Studies
Kent State University
Associate’s - Universal Science
Lorain County Community College
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