Patches Cox
Hamilton,AL
Summary
Adept at streamlining prior authorization processes, always striving to enhance provider and patient satisfaction. Strong knowledge in medical necessity, HIPAA compliance and strong organizational skills providing a marked improvement in workflow management. Excel in fostering productive relationships with healthcare providers, ensuring high approval rates for necessary treatments.
Professional coordinator with deep expertise in managing authorization processes within healthcare settings. Skilled in navigating complex regulatory environments, ensuring compliance, and streamlining workflows. Strong emphasis on achieving high-impact results, adaptable to changing needs. Reliable problem-solver with focus on communication, organization, and patient advocacy.
Personable and professional who possesses solid understanding of healthcare procedures and regulations, coupled with proficiency in data entry and communication. Dedicated to optimizing authorization processes to enhance patient care and operational efficiency.
Overview
5
5
years of professional experience
1
1
Certification
Work History
Prior Authorization Coordinator
Alabama Cancer Care
11.2023 - Current
- Improved patient satisfaction by efficiently managing prior authorization requests and ensuring timely approvals.
- Reduced errors in documentation by meticulously reviewing medical records and verifying patient information.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Authorized surgical requests in accordance with applicable plan guidelines.
- Triaged unscheduled and emergency authorizations, directing submissions to appropriate personnel for rapid response.
- Created and maintained spreadsheets detailing medical procedures and insurance denials and approvals.
- Maintained accurate case files, updating relevant information as needed to ensure efficient record-keeping practices.
- Optimized turnaround times for prior authorization requests, collaborating closely with physicians and clinical staff to expedite necessary treatments.
- Enhanced workflow management within the department, implementing strategies to prioritize urgent cases and manage workload effectively.
- Ensured compliance with state and federal regulations through diligent monitoring of prior authorization processes.
- Received and routed laboratory results to correct clinical staff members.
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
- Verified eligibility and compliance with authorization requirements for service providers.
- Tracked referral submission during facilitation of prior authorization issuance.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Maintained the confidentiality of sensitive patient information, adhering strictly to HIPAA regulations and safeguarding medical records appropriately.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Increased team efficiency by providing comprehensive training on prior authorization procedures for new hires.
Prior Authorization Specialist
Southeastern Physician Network
01.2021 - 11.2023
- Collaborated with physicians to obtain necessary clinical information for prior authorization submissions.
- Maintained thorough knowledge of insurance plan requirements, facilitating accurate and timely completion of authorization forms.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
- Achieved high success rate in obtaining authorizations by effectively demonstrating medical necessity through comprehensive documentation and clear communication with insurance companies.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Tracked referral submission during facilitation of prior authorization issuance.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Maintained organized records and up-to-date files for all completed and pending authorization requests, ensuring easy access during audits or reviews.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Advocated for patients by negotiating with insurance providers to cover necessary treatments not initially authorized.
- Supported healthcare providers by offering guidance on alternative treatment options when initial requests were denied.
- Increased approval rates for necessary medical procedures by providing detailed justifications and patient history during review process.
- Streamlined submission of prior authorization requests, leading to faster patient access to needed treatments.
- Improved patient outcomes by expediting authorization process for urgent and life-saving treatments.
- Enhanced efficiency in processing prior authorization requests by streamlining documentation procedures.
Community Health Worker
North Alabama Area Health Education Center
03.2020 - 11.2024
- Participated in ongoing professional development opportunities to stay current on best practices in community health work, ensuring the delivery of quality services to clients.
- Connected families with necessary social services, alleviating barriers to healthcare access and improving quality of life.
- Built trust within diverse communities through cultural competency training, empathetic communication skills, and active listening techniques.
- Worked directly with patient treatment teams and participated in care coordination procedures.
- Increased awareness of available resources by organizing and participating in community health fairs and events.
- Promoted access to healthcare services for underprivileged populations through community outreach efforts.
- Led outreach activities to target specific demographics and promote health initiatives.
- Collaborated with external organizations to coordinate health and social services.
- Coordinated immunization clinics in collaboration with local public health departments, increasing vaccination rates among vulnerable populations.
- Reduced hospital readmissions by collaborating with multidisciplinary teams to provide comprehensive care plans for patients.
- Developed and maintained relationships with community partners to build program scope.
- Enhanced patient outcomes by providing education on disease prevention and healthy lifestyle choices.
- Collaborated with healthcare providers to ensure comprehensive care coordination for patients transitioning between settings.
- Wrote and distributed informational materials on chronic diseases, infant mortality, substance abuse, and other community health concerns.
- Developed and implemented training classes to educate team members and community residents.
- Collaborated with local organizations to expand health services and resources.
- Organized health fairs and screenings, increasing early detection of chronic conditions and connecting individuals with treatment options.
- Collaborated with public health officials to develop emergency response plans for public health crises.
- Improved patient outcomes by coordinating care among multiple healthcare providers and managing comprehensive care plans.
- Trained new community health workers, sharing best practices and ensuring consistent quality of care across team.
- Set up community health education and promotion programs to reduce chronic conditions.
- Developed educational materials tailored to specific population needs, ensuring clarity and relevance for maximum impact on public health initiatives.
- Mediated communication between healthcare providers and clients, facilitating better understanding of medical information and treatment plans.
- Assisted clients in navigating complex healthcare systems by providing guidance on insurance coverage options and connecting them with appropriate providers or agencies.
Education
Associate of Applied Science - Business Administration
Bevill State Community College
Sumiton, AL05-2008
Skills
- Authorizations
- Benefit coverage
- HIPAA compliance
- Strong organization
- Retro-authorizations
- Insurance verification
- Medical terminology
- Data entry proficiency
Certification
- Advanced Cardiac Life Support (ACLS) - American Heart Association.
- Medical Terminology Certificate –Morehouse School of Medicine
- Microsoft Office Specialist, Microsoft Word, Excel, PowerPoint (MOS) - Microsoft Corporation.
- OSHA Certified
- First Aid Certification
- Microsoft Office Specialist (MOS) Certification
- Community Health Worker (Morehouse School of Medicine)
- HIPAA Compliance Certification (Morehouse School of Medicine)
- Prior Authorization Certification (Morehouse School of Medicine)
Timeline
Prior Authorization Coordinator
Alabama Cancer Care
11.2023 - Current
Prior Authorization Specialist
Southeastern Physician Network
01.2021 - 11.2023
Community Health Worker
North Alabama Area Health Education Center
03.2020 - 11.2024
- Advanced Cardiac Life Support (ACLS) - American Heart Association.
- Medical Terminology Certificate –Morehouse School of Medicine
- Microsoft Office Specialist, Microsoft Word, Excel, PowerPoint (MOS) - Microsoft Corporation.
- OSHA Certified
- First Aid Certification
- Microsoft Office Specialist (MOS) Certification
- Community Health Worker (Morehouse School of Medicine)
- HIPAA Compliance Certification (Morehouse School of Medicine)
- Prior Authorization Certification (Morehouse School of Medicine)
Associate of Applied Science - Business Administration
Bevill State Community College
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