Rachelle Donges
Mead
Summary
Detail-oriented professional in medical office operations, specializing in prior authorization processes. Proven track record in resolving discrepancies, educating patients on insurance benefits, and maintaining compliance with regulations, enhancing patient satisfaction and operational efficiency.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Prior Authorization Specialist Lead
Spokane Urology Ps
SPOKANE
04.2024 - Current
- Reviewed and analyzed insurance requests for prior authorization at Spokane Urology to ensure compliance and accuracy.
- Communicated with healthcare providers to gather necessary patient information.
- Submitted prior authorization requests through electronic systems and managed responses.
- Coordinated with insurance companies to resolve discrepancies in authorizations.
- Educated patients on insurance benefits and prior authorization processes, enhancing their understanding and reducing confusion.
- Maintained comprehensive records of prior authorization requests and outcomes to support effective tracking and reporting.
- Collaborated with medical staff to ensure timely processing of authorizations.
- Monitored changes in insurance policies affecting prior authorization requirements.
- Coordinated with other departments to obtain additional information needed for prior authorization.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Scheduled peer to peer reviews for physicians to discuss medical necessity with insurance providers.
- Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
- Notified ordering providers of denied authorizations.
- Maintained accurate records of all authorization activities in the database system.
- Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
- Responded promptly to inquiries from providers, patients and payers regarding status of prior authorization requests.
- Provided guidance to providers regarding the prior authorization process.
- Developed relationships with external vendors providing pre-authorization services.
- Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal communication skills.
- Maintained files for referral and insurance information, entering referrals into system.
- Processed appeals promptly following policy guidelines.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Assisted with developing policies and procedures related to prior authorizations.
- Facilitated communication between providers, payers and health plans regarding prior authorization processes.
- Identified areas where improvements could be made within the department by analyzing trends in denials and approvals.
- Advised provider offices on proper coding practices that are necessary for successful claim submission.
- Entered claims and prior authorization data into electronic system for processing.
- Determined which party would be liable for payment on medical services by thoroughly reviewing patient insurance coverage.
- Ensured compliance with state and federal regulations pertaining to prior authorizations.
- Monitored changes in insurance policies and guidelines to ensure compliance with prior authorization processes.
- Participated in multidisciplinary team meetings to discuss complex cases requiring prior authorization.
- Provided customer service to patients and healthcare providers, answering questions related to prior authorization and insurance coverage.
- Utilized medical coding knowledge to accurately process and document authorization requests.
- Trained new staff on prior authorization procedures and company policies.
- Developed and implemented process improvements to enhance efficiency and accuracy of prior authorization workflows.
- Communicated authorization decisions, including approvals and denials, to healthcare providers and patients.
- Assisted in the development of educational materials for patients about the prior authorization process and insurance benefits.
- Followed up on pending prior authorization requests to ensure timely processing.
- Maintained confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
- Explained eligibility details and affordability options to patients with kindness and respect.
Customer service representative
Premera blue cross
01.2023 - 10.2023
- Handled customer inquiries on health insurance policies and coverage options, ensuring clarity and understanding.
- Delivered timely resolution of customer complaints, enhancing overall customer satisfaction.
- Resolved claims issues through clear communication and effective problem-solving, leading to satisfied customers.
- Collaborated with team members to enhance service quality and customer satisfaction.
- Managed prior authorization requests effectively.
- Evaluated benefits and eligibility criteria.
- Processed insurance claims efficiently.
Designated Trainer
CSL Plasma
06.2022 - 01.2023
- Trained new staff on safety protocols and operational procedures.
- Conducted ongoing assessments to ensure compliance with regulatory standards.
- Mentored team members, enhancing skills in customer service and donor interaction to improve overall service quality.
- Collaborated with management to streamline training processes, resulting in more efficient program delivery.
- Provided feedback to improve training sessions based on participant performance.
- Evaluated performance of trainees against established criteria during post-training evaluations.
- Monitored progress of employees to ensure that job requirements were met in accordance with company policies and procedures.
- Provided expertise to trainees on safety, health, and environmental standards, ensuring compliance and fostering a culture of safety.
- Ensured compliance with applicable laws and regulations related to workplace safety and health.
Phlebotomist
CSL Plasma
03.2022 - 01.2023
- Collected blood samples from donors following strict safety protocols.
- Performed venipuncture and other blood collection procedures according to established standards.
- Located veins suitable for puncture to draw blood using sterilized needles, vials and other equipment.
- Prepared and labeled specimens for laboratory analysis and testing.
- Checked and confirmed patient information before proceeding with specimen collection to ensure accuracy.
- Monitored donor reactions and provided immediate care.
- Delivered compassionate support to donors during blood collection process, enhancing donor experience.
- Collaborated with medical team to ensure efficient donation processes and patient care.
- Delivered quality patient care by completing accurate and timely collection and transport of clinical specimens according to established procedures.
- Maintained clean and organized work area to ensure compliance with health standards.
- Adhered to HIPAA guidelines regarding patient privacy.
- Ensured accurate documentation of donation information in electronic health records system, maintaining data integrity.
- Facilitated training for new staff on phlebotomy techniques and equipment use, contributing to team skill development.
- Assisted in the training of new phlebotomists.
- Collected specimens from pediatric, adult, geriatric, and special needs patients.
- Responded quickly and effectively to emergency situations.
Donor support technician
CSL Plasma
12.2021 - 01.2023
- Applied antiseptic techniques when placing gauze and Coban on venipuncture site to promote donor safety and prevent infection.
- Disconnected donors from plasma machines, ensuring safe removal and compliance with health standards.
- Utilized internal database to accurately process donor payouts and document machine alarms, enhancing operational tracking.
Customer service representative
LINCARE
09.2019 - 12.2019
- Handled customer inquiries on health insurance policies and coverage options to provide clear guidance.
- Resolved claims issues through effective communication and problem-solving skills.
- Addressed client billing questions and facilitated payment processing to ensure timely resolutions.
- Educated customers about plan benefits and network providers for informed decisions.
- Teamed with colleagues to improve service quality and increase customer satisfaction.
- Documented customer interactions accurately in the case management system.
Customer service representative
Express scripts
11.2014 - 10.2016
- Managed customer inquiries regarding health insurance policies and coverage options.
- Assisted clients with billing inquiries and payment processing, ensuring accurate and timely resolution.
- Resolved claims issues through effective communication and problem-solving skills.
- Educated customers about plan benefits and network providers for informed decisions.
- Collaborated with team members to improve service quality and boost customer satisfaction scores.
- Documented customer interactions accurately in the case management system.
- Streamlined complaint handling processes, resulting in quicker response times and enhanced customer experience.
- Answered customer inquiries and provided accurate information regarding products and services.
Caregiver
Home care of Washington
06.2008 - 03.2009
- Provided personal care and companionship to clients in their homes.
- Assisted clients with daily living activities, including bathing and dressing.
- Managed medication schedules and ensured adherence to treatment plans.
- Administered prescribed medications on a timely basis following care plan instructions.
- Followed care plan and directions to administer medications.
- Observed patients for changes in physical, emotional, mental or behavioral condition and injuries.
- Provided emotional support for clients who were experiencing depression or anxiety due to their illness or disability.
- Encouraged independence while promoting self-care skills such as bathing, grooming and toileting needs.
- Enhanced patient outlook and daily living quality through compassionate care.
- Maintained cleanliness and safety of client living environments.
- Helped maintain the safety of the client's environment by removing hazards such as rugs or furniture that could cause falls.
- Assisted with ambulation by providing support during transfers from bed to chair or wheelchair.
- Provided support for mobility to enhance independence of disabled individuals.
- Coordinated transportation for medical appointments and social activities.
- Drove clients to shop for groceries, attend doctor appointments and run errands.
- Performed light housekeeping tasks related to the client's care such as laundry and changing linens.
- Prepared meals according to dietary requirements and assisted with feeding.
- Communicated effectively with family members regarding client needs and progress.
- Documented changes in client conditions for health professionals' review.
- Established safe, positive living environments by effectively communicating client concerns with family and staff.
- Monitored behavioral and physical condition changes, promptly reporting potential medical issues to supervisor.
- Respected the rights of each individual client while maintaining confidentiality of all personal information.
- Encouraged residents to participate in activities of daily living to enhance personal dignity.
- Followed safe lifting and transferring techniques to transport residents.
- Drove clients to shop for groceries, attend doctor appointments and run errands.
- Maintained accurate records of services provided, changes in client condition, medications administered and other pertinent information.
Education
Business technology - Medical office receptionist, Medical clerical
Spokane Community College
Spokane, WA06-2023
Skills
- Prior authorization
- Insurance verification
- Precertification process
- Authorizations
- Retro-authorizations
- Utilization review
- Patient referrals
- Insurance procedures
- Insurance oversight
- EHR proficiency
- Data entry
- Analytical thinking
- Benefit coverage
- Credential verification
- Perform scheduling
- Patient scheduling
- Record keeping
- Critical thinking
- Analytical thinking
- Detail orientation
- Time management
- Organizational skills
- Computer proficiency
- Effective communication
- Problem solving
- Patient advocacy
- Confidentiality compliance
- HIPAA compliance
- Training coordination
- Training coordination
- Credential verification
- Problem solving
- Patient advocacy
- Patient advocacy
Certification
- Medical office certification, 2022
- Medical clerical assistant certification, 2022
- Medical assistant certified phlebotomist, 2022
Professional References
- Kallie Griffey, Call center specialist, 509.904.7741, kallieg95@gmailcom
- Melanie King, prior authorizations specialist, 509.944.0439, mking2860@comcast.net
- Brandi Kendrick, HCA, 509.202.9578
Timeline
Prior Authorization Specialist Lead
Spokane Urology Ps
04.2024 - Current
Customer service representative
Premera blue cross
01.2023 - 10.2023
Designated Trainer
CSL Plasma
06.2022 - 01.2023
Phlebotomist
CSL Plasma
03.2022 - 01.2023
Donor support technician
CSL Plasma
12.2021 - 01.2023
Customer service representative
LINCARE
09.2019 - 12.2019
Customer service representative
Express scripts
11.2014 - 10.2016
Caregiver
Home care of Washington
06.2008 - 03.2009
Business technology - Medical office receptionist, Medical clerical
Spokane Community College