Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Priscilla Macias

GLENDALE,AZ

Summary

Dedicated professional with a strong work ethic and proven ability to excel both independently and collaboratively. Seeking opportunities to contribute effectively to organizational success while enhancing client satisfaction. Committed to continuous personal and professional development.

Overview

13
13
years of professional experience
1
1
Certification

Work History

Phx,AZ Claims Processor

United Healthcare/Optum/Military and Veterans
12.2022 - 02.2023
  • Process prior authorizations in multiple states, also call providers to verify different services that was provided
  • Receive clinicals from the providers once received I would send it to the nurse
  • Data Entry
  • Approve behavioral health services per BH guidelines
  • Enter Referrals, Outpatient/Inpatient notifications for the Active-Duty service members and they’re families
  • If unable to approve requests, send it to the nurses for review.
  • Call the providers if we need more information
  • Check eligibility through the DEERS system
  • Rework referrals

Phx,AZ Medical Claims Processor

WPS
01.2022 - 02.2022
  • Process variety of medical claims for active military
  • Split claims whether it’s because of different years on a claim or if certain codes need to be all on one claim
  • Update personal information if need be for the claim to get reprocessed
  • Work different edits to reprocess the claim
  • Data Entry
  • Update any other information on the patient record
  • Send claims to different departments to review or reprocess.
  • Data Entry
  • Process Veterans Affairs Inpatient, Outpatient
  • Deny claims
  • Manually route claims to TriWest Healthcare for further review
  • Facets,CareRadius, Sjynet 4.0, Unity (Onbase)

Phx,AZ VA Claims Processor

WPS
11.2019 - 10.2020
  • Process variety of medical claims for active military
  • Split claims whether it’s because of different years on a claim or if certain codes need to be all on one claim
  • Update personal information if need be for the claim to get reprocessed
  • Work different edits to reprocess the claim
  • Data Entry
  • Update any other information on the patient record
  • Send claims to different departments to review or reprocess.
  • Data Entry
  • Process Veterans Affairs Inpatient, Outpatient
  • Deny claims
  • Manually route claims to TriWest Healthcare for further review
  • Facets,CareRadius, Sjynet 4.0, Unity (Onbase)

Phx,AZ Data Resolution Specialist

Triwest Healthcare Alliance
02.2016 - 10.2019
  • Train new employees
  • Research VA denied claims
  • Process claims and send them back to WPS Health Solutions to manually price or further review
  • Audit new employee’s work
  • Update providers address and any other information in Facets
  • Work in Facets, Anchor Point, Visual Cactus, Emotoris, CareRadius, Unity (OnBase)

Phx,AZ Clinical Admin Coordinator

United Healthcare/Optum/Military and Veterans
11.2015 - 02.2016
  • Process prior authorizations in multiple states, also call providers to verify different services that was provided
  • Receive clinicals from the providers once received I would send it to the nurse
  • Data Entry
  • Approve behavioral health services per BH guidelines
  • Enter Referrals, Outpatient/Inpatient notifications for the Active-Duty service members and they’re families
  • If unable to approve requests, send it to the nurses for review.
  • Call the providers if we need more information
  • Check eligibility through the DEERS system
  • Rework referrals

Phx,AZ Behavioral Health Prior Authorization Specialist

United Healthcare/Optum/Military and Veterans
02.2013 - 11.2015
  • Process prior authorizations in multiple states, also call providers to verify different services that was provided
  • Receive clinicals from the providers once received I would send it to the nurse
  • Data Entry
  • Approve behavioral health services per BH guidelines
  • Enter Referrals, Outpatient/Inpatient notifications for the Active-Duty service members and they’re families
  • If unable to approve requests, send it to the nurses for review.
  • Call the providers if we need more information
  • Check eligibility through the DEERS system
  • Rework referrals

Phx,AZ -Consult Tracker

Triwest Healthcare Alliance
03.2010 - 01.2012
  • Train new employees
  • Research VA denied claims
  • Process claims and send them back to WPS Health Solutions to manually price or further review
  • Audit new employee’s work
  • Update providers address and any other information in Facets
  • Work in Facets, Anchor Point, Visual Cactus, Emotoris, CareRadius, Unity (OnBase)
  • Fax patients reports to the Military Bases
  • Call providers to get patients information if need be
  • Research different Authorizations, put reports in the correct auth

Education

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University of Phoenix
10.2024

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Arizona Institute of Business and Technology
03.2001

Skills

  • Claims review
  • Accuracy and precision
  • Transactions reconciliation
  • Claims

Certification

Medical billing and coding

Timeline

Phx,AZ Claims Processor

United Healthcare/Optum/Military and Veterans
12.2022 - 02.2023

Phx,AZ Medical Claims Processor

WPS
01.2022 - 02.2022

Phx,AZ VA Claims Processor

WPS
11.2019 - 10.2020

Phx,AZ Data Resolution Specialist

Triwest Healthcare Alliance
02.2016 - 10.2019

Phx,AZ Clinical Admin Coordinator

United Healthcare/Optum/Military and Veterans
11.2015 - 02.2016

Phx,AZ Behavioral Health Prior Authorization Specialist

United Healthcare/Optum/Military and Veterans
02.2013 - 11.2015

Phx,AZ -Consult Tracker

Triwest Healthcare Alliance
03.2010 - 01.2012

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University of Phoenix

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Arizona Institute of Business and Technology

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Priscilla Macias