Summary
Overview
Work History
Education
Skills
Accomplishments
Certification
References
Timeline
Generic

Stasia Sefton

Hydesville,CA

Summary

Detail-oriented professional with experience in Medicare and Medicaid prior authorizations, Microsoft Office, and various EMR systems. Frequently praised as hardworking by upper leadership, with an in-depth understanding of medical standards, compliance requirements and operational procedures. Experience with electronic recordkeeping and insurance documentation. Skilled at operating with little oversight to complete tasks efficiently, as well as working remotely in a PHI approved setting.

Overview

16
16
years of professional experience
1
1
Certification

Work History

Care Review Processor/Case Management Processor

Molina Healthcare
Hydesville, CA
03.2022 - Current
  • Review prior authorization requests for completeness and accuracy.
  • Submit prior authorization requests electronically or by phone to payers.
  • Respond promptly to inquiries from providers, members, and other departments within the organization.
  • Provide guidance to providers regarding the prior authorization process.
  • Coordinate with other departments to obtain additional information needed for prior authorization.
  • Research clinical criteria and determine eligibility for requested services based on plan provisions.
  • Collaborate with internal staff members to resolve discrepancies or issues related to prior authorizations.
  • Ensure compliance with state and federal regulations pertaining to prior authorizations.
  • Interpret benefit language in order to determine covered services under each plan type.
  • Apply knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
  • Verify patient insurance coverage, including eligibility, benefits and authorizations for medical services.
  • Use UMK2, QNXT and PEGA to input prior authorization and other important medical data into system.
  • Determine which party would be liable for payment on medical services by thoroughly reviewing patient insurance coverage.
  • Maintain confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
  • Maintain positive working relationship with fellow staff and management.
  • Proofread documents carefully to check accuracy and completeness of all paperwork.
  • Review and process prior authorization requests from healthcare providers to determine eligibility for services.
  • Research and resolve any discrepancies between provider documentation and insurance company requirements.
  • Advise providers on submission of correct information for timely processing of authorization requests.
  • Implement best practices within the department that improve efficiency without compromising quality standards set forth by regulatory agencies.

Data Specialist/Administrative Assistant

St. Joseph Hospital Eureka
Eureka, CA
01.2008 - 03.2013
  • Created automated reports from large datasets for senior management review.
  • Identified areas of improvement in existing database systems and implemented solutions accordingly.
  • Provided administrative support to the executive team, including scheduling meetings and managing calendars.
  • Organized and maintained filing systems for physical and electronic documents, ensuring accuracy and confidentiality of records.
  • Composed letters, memos, reports, emails, presentations and other written correspondence as required by management staff.
  • Managed incoming calls while providing information or transferring callers to appropriate personnel.
  • Maintained office supplies inventory by checking stock to determine inventory level; anticipating needed supplies; placing and expediting orders for supplies.
  • Ensured efficient operation of office equipment such as printers, copiers and fax machines.
  • Created travel arrangements for senior managers according to their requirements.
  • Coordinated mailings including sorting mail, preparing packages for shipping via courier service or postal service.
  • Entered data into spreadsheets using Microsoft Excel or other similar programs.
  • Handled confidential documents in an organized fashion according to established protocol.
  • Provided secretarial and office management support while building cooperative working relationships.
  • Developed administrative processes to achieve organizational objectives and improve office efficiency.
  • Facilitated review, revision, and maintenance of hospital-wide policies and procedures.

Education

Bachelor of Science - Sociology

Fort Hays State University
Hays, KS
12-2010

Skills

  • Insurance knowledge
  • Healthcare knowledge
  • Medical Coding
  • Data Entry
  • Electronic Recordkeeping
  • Medical Terminology
  • Insurance Verification
  • Critical Thinking
  • Outpatient Procedures
  • Attention to Detail
  • Insurance Authorizations
  • Reliability
  • Medicaid billing procedures
  • Patient Health Information Access
  • Multitasking
  • Administrative Support
  • Medicare Compliance

Accomplishments

  • Meets quality performance measures with 99% accuracy per monthly audits.
  • Exceeded expectations by upper leadership at last performance review in January.
  • Versatile in Inpatient and Outpatient authorizations.
  • High marks on all performance reviews and monthly 1:1 with management.

Certification

Certified Professional Coder (CPC-A)

AAPC Member ID: 01861515

References

References available upon request.

Timeline

Care Review Processor/Case Management Processor

Molina Healthcare
03.2022 - Current

Data Specialist/Administrative Assistant

St. Joseph Hospital Eureka
01.2008 - 03.2013

Bachelor of Science - Sociology

Fort Hays State University

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Stasia Sefton