Nikey Cesar
MA
Summary
Accomplished Prior Authorization Specialist with a proven track record at aequor showcasing expert understanding of Medicare and Medicaid alongside exceptional customer service. demonstrated 98-100% audit accuracy, and excelled in mentoring new hires. Skilled in medical terminology and HIPAA, achieving a balance of efficiency and meticulous attention to detail. 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 5 years of managing documentation. Considered team player with exemplary multitasking skills.
Overview
2
2
years of professional experience
Work History
Prior Authorization Specialist
Aequor
11.2020 - 01.2023
- Responsible for providing excellent customer service over the phone for members, pharmacies, and providers.
- Accountable for the review of prior authorization requests using prior authorization guideline question and answer protocol.
- Assisted pharmacies in prior authorization claims processing by giving information needed to process the claim such as prior auth number, medication information, etc.
- Input call tracking notes with each call received or made throughout the prior authorization process.
- Provided pertinent information to members, physicians, and pharmacies regarding but no limited to co-pay info, plan design, medication alternatives.
- Maintained professional competence, knowledge, and skills necessary to effectively and accurately complete Medicare Part D responsibilities,
- Maintained knowledge of current drug info and new releases of drugs or their generic.
- Maintained average handling time of five minutes per call in which prior auth was processed.
- Maintained 98-100% audit scores for all phone calls.
- Assisted in the New Hire training process as a mentor and auditor.
- Processed 10 faxed in prior authorizations on a daily basis.
- Part of the Escalations team; Assisted trouble shooting requests that were incomplete.
- Part of the Escalations team; Assisted trouble shooting requests that would not adequately pay out.
- Reduced turnaround time for prior authorization decisions by implementing more efficient review process.
- Participated in cross-functional initiatives to improve overall efficiency and effectiveness of the prior authorization process for all involved parties.
- Achieved high success rate in obtaining authorizations by effectively demonstrating medical necessity through comprehensive documentation and clear communication with insurance companies.
- Collaborated with physicians to obtain necessary clinical information for prior authorization submissions.
- Managed a high volume of incoming calls, maintaining professionalism while effectively addressing the needs of callers seeking assistance with prior authorizations.
- Maintained thorough knowledge of insurance plan requirements, facilitating accurate and timely completion of authorization forms.
- Verified eligibility and compliance with authorization requirements for service providers.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
Prior Authorization Coordinator
Triage
12.2020 - 12.2022
- Verified eligibility and compliance with authorization requirements for service providers.
- Maintained accurate case files, updating relevant information as needed to ensure efficient record-keeping practices.
- Maintained the confidentiality of sensitive patient information, adhering strictly to HIPAA regulations and safeguarding medical records appropriately.
- Collected and processed patient liability statements prior to service.
- Reduced errors in documentation by meticulously reviewing medical records and verifying patient information.
- Created and maintained spreadsheets detailing medical procedures and insurance denials and approvals.
- Triaged unscheduled and emergency authorizations, directing submissions to appropriate personnel for rapid response.
- Exhibited strong attention to detail when evaluating eligibility criteria for medication coverage, minimizing instances of inappropriate denials or delays in treatment access.
- Authorized surgical requests in accordance with applicable plan guidelines.
- Provided empathetic support for patients navigating complex medical systems, offering guidance and assistance throughout the prior authorization process.
- Expedited the approval process for vital medications by maintaining a strong working relationship with insurance providers.
Education
High School Diploma - High School Diploma
West Leyden High School
Northlake, IL2007
Certificate of Completion - Pharmacy Technician Training
Triton College
River Grove, IL2007
Skills
- Expert understanding of Medicare and Medicaid processes
- Excellent telephone etiquette
- HIPAA trained
- Medical terminology knowledge
- HIPAA Compliance Knowledge
- Insurance procedures
- Effective communication skills
- Professionalism and Ethics
- Billing Procedures
- Critical thinking abilities
- Insurance Verification
- Excellent customer service skills
- Attention to detail
Custom
Timeline
Prior Authorization Coordinator
Triage
12.2020 - 12.2022
Prior Authorization Specialist
Aequor
11.2020 - 01.2023
High School Diploma - High School Diploma
West Leyden High School
Certificate of Completion - Pharmacy Technician Training
Triton College
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