Williams
Marshall,TX
Summary
Serve as the primary point of contact (POC) for team members, provider offices, and patients regarding medication prior authorizations.
• Act as a key liaison between providers, insurance payers, and patients to facilitate timely access to covered care.
• Review medical records, provider requests, and clinical documentation to ensure completeness and medical necessity.
• Verify patient insurance eligibility and benefits prior to authorization submission.
• Ensure accuracy of ICD-10 and CPT codes to support billing and authorization approval.
• Maintain detailed, accurate documentation of authorizations and communications in compliance with HIPAA regulations.
• Perform administrative tasks including data entry, authorization tracking, and system updates.
• Support and mentor team members while demonstrating strong collaboration, dependability, and self-motivated
Overview
4
4
years of professional experience
1
1
Certification
Work History
Prior Authorization Representative
Aetna, a CVS Health
Remote
09.2021 - Current
- Reviewed and processed prior authorization requests for medical services to ensure compliance with company policies.
- Communicated effectively with healthcare providers to gather necessary documentation for authorization decisions.
- Maintained accurate records of authorization requests and outcomes using internal systems for tracking purposes.
- Collaborated with team members to streamline workflows, improving turnaround times for approval processes.
- Assisted in training new staff on protocols and systems related to prior authorization processes and best practices.
- Analyzed trends in authorization requests, providing feedback to improve service delivery and efficiency metrics.
- Provided exceptional customer service, addressing inquiries from both patients and healthcare providers promptly and professionally.
- Ensured compliance with HIPAA regulations by maintaining strict confidentiality in handling sensitive patient information.
- Verified eligibility and compliance with authorization requirements for service providers.
- Processed new medication and refill requests for authorization.
- Communicated pertinent information to client's prescribing provider to facilitate quality service.
- Streamlined workflow for faster approval turnaround times, handling high volume of insurance verification tasks.
- Collaborated with healthcare providers to expedite the process of obtaining necessary medical documentation for approvals.
- Reduced claim denials by thoroughly reviewing and analyzing medical necessity documentation before submitting for approval, ensuring all criteria were met.
- Reduced errors in documentation by meticulously reviewing medical records and verifying information accuracy.
- Contributed to departmental success by consistently meeting or exceeding performance metrics such as accuracy, productivity, and quality standards.
Education
High School Diploma -
Marshall High School
Marshall, TXSkills
Prior Authorization Management Insurance Verification & Benefits
Medical Terminology HIPAA Compliance
Medical Coding (ICD-10, CPT) Clinical Criteria Review
Strong Verbal & Written Communication Multitasking
Attention to Detail Time Management
Fast Learner Analytical & Critical Thinking Skills
Certification
Cpht
Timeline
Prior Authorization Representative
Aetna, a CVS Health
09.2021 - Current
High School Diploma -
Marshall High School