Shirley Joseph

• Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service
• Reviewed prior authorization requests for specialty medications, infusions, and procedures, ensuring medical necessity and payer policy compliance.
• Submitted PA requests to insurance carriers through electronic portals and fax systems, reducing approval turnaround times.
• Verified insurance eligibility and benefits for patients, including coverage limits, copay requirements, and step therapy protocols.
• Coordinated with providers, nurses, and pharmacists to gather required documentation (e.g., chart notes, lab results, medication histories) to support authorization requests.
• Communicated authorization approvals, denials, and appeals to providers and patients in a clear and timely manner.
• Tracked authorization status and followed up with insurance companies to prevent delays in patient care.
• Maintained knowledge of payer-specific criteria for specialty drugs (e.g., Botox, Inflectra, Tezspire, Remicade) and updated internal databases as policies changed.
• Handled high-volume prior authorization requests while maintaining accuracy, compliance, and HIPAA confidentiality.
• Calculated units and billing totals for infusion and specialty medications (e.g., HCPCS J-codes, unit per dose, number of doses, and total HCPCS units).

• Verifying insurance eligibility and benefits.
• Explaining coverage and authorization requirements.
• Assisting members with claims questions.

Coordinating with providers, pharmacies, and insurance departments.

• Answered incoming calls and provided highest level of professionalism and knowledgeable service to every customer
• Updated customer accounts, addresses and contact information within call management databases
• Set up and activated customer accounts
• Escalated customer concerns, issues and requirements to supervisors for immediate rectification
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• Informed customers about billing procedures, processed payments and provided payment option setup assistance
• Evaluated appeals from denied claims according to established protocols for resolution in accordance with payer
• guidelines.
• Analyzed data to identify trends in submitted claims, ensuring the accuracy of payments made to healthcare
• providers.
• Adhered to HIPAA regulations while maintaining confidentiality of patient information at all times.
• Analyzed insurance benefits, coverage limitations, network restrictions, provider contracts, and other factors
• related to prior authorization requests.

• Maintained positive attitude and effectively de-escalated clients during crisis situations
• Provided referrals to appropriate resources within the community when necessary
• Trained volunteers in customer service policies and procedures
• Built positive relationships with customers by providing friendly and helpful service
• Efficiently handled customer complaints in a courteous manner, resolving issues quickly and effectively
• Processed returns, exchanges, and refunds in accordance with store policy
• Resolved customer complaints by exchanging merchandise, refunding money, or adjusting bills
• Assisted customers with locating products throughout the store and provided product knowledge information as needed
• Applied suggestive selling techniques to increase sales