Sean Norton

This new role allowed myself to transfer into a team lead position. In charge of daily emails requesting changes to authorization, requests for authorizations, completing reports for different vendors, troubleshooting issues with auth errors, overlapping issues, non-par providers. Assisting with new market / vendor launches, creating and editing job aids.

I was promoted to this role to start the Turning Point vendor project. This vendor was used to review MSK and later on Cardiac procedures for the Florida plan. My responsibilities included to receive a daily spreadsheet from Turning Point with approved, partially approved, or denied files that I would convert into authorizations (inpatient and outpatient) within our system. Later on, I was also given New Century Health vendor files to build and determine authorizations within our system. Handle email traffic between vendors, clinical team, and different departments. I was also tasked with handling medical records faxed to us which would include date of service & facility changes on authorizations, clinical files that needed to be attached to authorizations for review. I was moved to my current manager's team to continue with Turning Point, NCH authorization's, assist with daily issues via email or instant messaging.

I was part of the intake authorization team. Our responsibilities were to take inbound calls from providers to build authorizations over the phone. Go over authorization statuses, escalate issues to the clinical team. Between calls I would build authorizations from faxes through Filenet or authorization requests submitted through the online portal such as elective inpatient requests, outpatient procedures like, sleep studies, surgery, pain, drug and genetic testing, non-par providers. Making outbound calls to Hospitals to verify inpatient admits, attaching documents to authorizations that were faxed in.

Was part of the first Ambetter team that assisted with both member and provider support. Our responsibility was to assist members with their policy info such as deductible and co-pay information, what has been met financially, what amount remains, taking payments over the phone for monthly premiums. Explaining claims payouts and Explanation Of Benefits. Locating provider and facility, filing grievances when needed, de-escalating issues. When providers called in, I would verify benefits, deductible and co-pay information, eligibility dates, authorization and claims explanations, and online provider support for ambetterfromsunshinehealth.com

• My role within this department was to answer inbound calls from Medicaid members with questions about their coverage, issues with care/filing grievances, locating providers/facilities near their home area. I was later transferred to provider services. My responsibilities were to address provider issues such as member eligibility, authorization and claim inquiries, filing grievances, provider online portal technical support for sunshinehealth.com.