Shalah Krup
Viola,IL
Summary
Dynamic Prior Authorization Specialist with a proven track record at UnityPoint Clinic, excelling in insurance verification and effective communication. Achieved a high success rate in obtaining authorizations through comprehensive documentation and process improvements, enhancing workflow efficiency and patient understanding. Skilled in medical terminology and committed to maintaining HIPAA compliance.
Overview
17
17
years of professional experience
Work History
Prior Authorization Specialist
UnityPoint Clinic
Remote
07.2009 - Current
- Processed prior authorization requests efficiently, ensuring timely communication with healthcare providers and patients.
- Reviewed clinical documentation for accuracy, verifying compliance with insurance guidelines and policies.
- Collaborated with medical staff to gather necessary information for approval submissions, enhancing workflow efficiency.
- Educated patients on prior authorization processes, improving understanding and reducing call volume related to inquiries.
- Maintained updated knowledge of insurance requirements and regulations, ensuring adherence to industry standards in submissions.
- Assisted in training new team members on procedural workflows and best practices in prior authorization processes.
- Implemented process improvements that reduced turnaround times for authorization approvals by streamlining documentation handling.
- 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.
- Verified eligibility and compliance with authorization requirements for service providers.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Achieved high success rate in obtaining authorizations by effectively demonstrating medical necessity through comprehensive documentation and clear communication with insurance companies.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
- Provided training to new staff members on the intricacies of various insurance plans and their specific prior authorization requirements.
- 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.
- Managed a high volume of incoming calls, maintaining professionalism while effectively addressing the needs of callers seeking assistance with prior authorizations.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Maintained organized records and up-to-date files for all completed and pending authorization requests, ensuring easy access during audits or reviews.
- Supported team members by providing guidance on complex cases requiring detailed understanding of medical necessity criteria.
- Enhanced communication between healthcare providers and insurance companies, ensuring prompt resolution of issues related to prior authorizations.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
Education
High School Diploma -
Northwest High School
Omaha, Ne05.1995
Skills
Prior authorization process
Medical terminology
Medical appeals handling
Authorizations
Insurance verification
Effective communication skills
Data entry
Medical terminology knowledge
Physician order verification
Medical office procedures
Professionalism and ethics
Process improvement strategies
Workflow management
Insurance procedures
Retro-authorizations
Patient confidentiality compliance
Records maintenance
Provider relations
Utilization review experience
Proficiency in software
Clinical documentation improvement
Critical thinking
HIPAA compliance
CPT coding
Precertification requirements
Outpatient surgery coding
Eligibility determination
Referral coordination
Multitasking
Problem-solving
Telephone etiquette
Documentation and paperwork
Timeline
Prior Authorization Specialist
UnityPoint Clinic
07.2009 - Current
High School Diploma -
Northwest High School