Stacie Rivera

Initiates and processes Medicare prior authorizations for medical procedures in a timely manner in compliance with guidelines.

Serves as a subject matter specialist for authorization workflows, processes, and compliance standards.

Provides guidance and supports team members by resolving case-related inquiries, procedural questions, and escalations.

Collaborates with interdisciplinary teams to resolve authorization challenges and inquiries.

Ensures service levels are met by maintaining operational efficiency.

Participates in the hiring, mentoring, and training of new hires. Contributing to team development and operational productivity.

Generates and modifies Medicare prior authorizations for medical procedures and DME items via telephone, fax and/or other internal departments. Obtains required documentation from providers such as principal diagnosis and procedure codes, as well as provider profile information.

Operates internal and external systems to verify member eligibility and provider network status such as name, address, NPI and Tax ID.

Executes activities, including but not limited to, inbound/outbound calls as assigned, faxes, and emails. Maintains accurate hospital census reports pertaining to concurrent reviews. Creates and documents approval/denial authorization letters for members and providers.

Partners in investigating complex issues from internal/external departments as they relate to any concerns, discrepancies and/or inquiries from providers such as eligibility, authorization process, claims, etc.

Executes follow-up, as necessary, to ensure provider and member satisfaction and successful delivery of service.

Educates new hires and provides continuing guidance where needed to staff as well as supports with Managed Long Term Care and Select Health lines of business when needed.

Triages provider calls with minimal wait time while maintaining strong customer service and ensuring established call performance targets are consistently achieved. Maintains courteous and effective working relationships.

Protects the confidentiality of member information and adheres to company policies regarding confidentiality/HIPPA and CMS guidelines.

Administered as the primary contact for Managed Long Term Care members with inquiries related to nurse and/or home health aide scheduling, DME supplies, transportation, insurance benefits and provider information. Updated databases to handle member data.

Investigated and resolved member inquiries and complaints through thorough investigation in a timely manner. Structured follow-ups with members regarding resolved issues to maintain high standards of customer service.

Acquired and maintained updated knowledge of internal processes and industry best practices to optimize service delivery.

Optimized member support by establishing collaborative service environments through targeted operational initiatives.

Executed department customer call guidelines for service levels, handle time and productivity while exhibiting high energy and professionalism when addressing clients and staff.

Educated staff on operating procedures and company services. Partnered with staff members to enhance member service experience and exceeded team goals through effective member satisfaction.

Facilitated with ensuring compliance with VNS Health policies and procedures.

Established appropriate staff-to-patient ratios for travel arrangements and strategically organized staffing schedules within review process.

Identified patient needs and potential concerns, establishing constructive approaches to expanding offerings. Examined analysis and process alternatives to arrive at best practices.

Gathered data from participating patients in the Acute/CHHA program through telephone contact and implemented their needs.

Coordinated with team members in setting of team goals and establishing performance.

Contributed operational needs with business staff in various departments. Translated business priorities into implementable actions.