ROMELA RENE
Valley Stream,NY
Summary
Detail-oriented Prior Authorization Specialist and Claims Adjuster with four years of experience in the healthcare industry. Skilled in communicating information, resolving patient issues, and building strong relationships to enhance patient satisfaction. Seeking to leverage expertise in a medical team dedicated to operational efficiency and growth.
Overview
6
6
years of professional experience
Work History
Claims Adjuster
United Health Care
Remote, Remote
05.2024 - Current
- Assessing insurance claims to guarantee accuracy and adherence to company guidelines.
- Identified and prevented fraudulent claims through thorough investigation and analysis.
- Identified discrepancies between insurer's files and provider's accounts receivable systems.
- Handling approximately 1000-2000 claims each month
- Coordinated with departments for thorough examination of claims, facilitating efficient collaboration.
- Handled complex claims while maintaining confidentiality.
- Confirming accurate benefits application alongside relevant CPT for OON/INN providers
- Analyzing medical documentation concerning referrals, scripts, authorizations, and medical clearances.
- Analyzed claims in high-velocity, data-driven environment, optimizing workflow for timely resolution.
- Overseeing multiple system operations utilizing three monitors
Pulmonary Prior Authorization Specialist
Northwell Health
Manhasset, NY
09.2022 - 03.2024
- Engaging with insurance providers to confirm coverage and acquire authorizations for medical procedures, such as sleep disorders, through direct platforms of insurance.
- Notified patients and providers of claim status following approval or denial, facilitating timely communication and next steps.
- Issue denial letters once authorization is not approved, enabling providers to assess appeal or P2P options based on medical criteria for each patient.
- Execute the submission of authorizations, ensuring accuracy and adherence to deadlines.
- Upholding HIPAA privacy standards with patient demographics and medical records.
- Managing direct communications with providers and insurance companies.
- Monitored decision progress and acquired benefits prior to appointments, ensuring patients received timely authorization and minimizing delays.
- Utilized clinical notes for medical policy assessment to determine patient eligibility for prior procedures and DME.
- Organized and filed patient clinical notes, ensuring essential documentation is printed prior to patient appointments to enhance office efficiency.
- Assisted patients with inquiries regarding prior authorization process and benefits requiring payment.
Patient Care Coordinator
GardenOBGYN
Plainview, NY
01.2021 - 09.2022
- Upholding confidentiality of patient data
- Engage with patients to ensure outstanding and focused patient care.
- Handled incoming calls and coordinated appointments proficiently on calendar to optimize time utilization.
- Facilitated seamless communication by routing calls to appropriate departments.
- Transmit results to medical offices and consult patients about vital information.
- Coordinated critical procedures and surgeries.
- Contacted providers for required service referrals.
- Updated demographics and structured medical records for each patient.
Brand/Communications Specialist
H&M
10.2019 - 01.2021
- Contributed to branding strategies alongside marketing specialists
- Projecting positive energy and maintaining an approachable attitude to effectively support requirements of customers
- Delivered outstanding customer service while addressing inbound calls.
- Transferring calls for customers and service advisors regarding product status updates
- Exhibited new products alongside dynamic marketing approaches emphasizing engaging appeal.
Education
Undergraduate - Clinical Psychology
Nassau Community College
long island, ny07.2021
High School Diploma - Valley Stream, ny
Central High School
Valley Stream, ny06.2015
Some College (No Degree) - Clinical Psychology
Hofstra University
Hempstead, NYSkills
- Analytical skills
- Methodical
- Diligence
- Team-oriented
- Rapid learner
- Operational strategist
- Solutions-oriented strategist
- Data analytics
- Clinical researcher
- Attention to detail
- Proficiency in all Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint
- Proficient in medical terminology
- Medical coding
- Medicare and Medicaid
- CPT/ICD-10
- Proficient in EHR, SORIAN, Allscripts, Athena, and direct insurance websites
- Medical document scanning
- Data analysis
- HIPAA training
- Technical skills
- Clinical records management
- Critical thinking
- CIS experience
- Time management
- Multitask efficiency
- Fast-paced environments
- Collaborative skills
Languages
English
Native/ Bilingual
French
Limited
Creole
Limited
Timeline
Claims Adjuster
United Health Care
05.2024 - Current
Pulmonary Prior Authorization Specialist
Northwell Health
09.2022 - 03.2024
Patient Care Coordinator
GardenOBGYN
01.2021 - 09.2022
Brand/Communications Specialist
H&M
10.2019 - 01.2021
Undergraduate - Clinical Psychology
Nassau Community College
High School Diploma - Valley Stream, ny
Central High School
Some College (No Degree) - Clinical Psychology
Hofstra University