Yerenis Garcia
Morriston,USA
Summary
Revenue Cycle and Authorization Specialist with extensive healthcare experience in oncology, genetic testing, and behavioral health. Focused on enhancing patient care through efficient authorization processes and interdisciplinary collaboration.
Overview
9
9
years of professional experience
Work History
CASE MANAGER
University of Miami
Miami, FL
11.2024 - Current
- Ensure treatment plans align with NCCN guidelines and payer-specific medical necessity criteria prior to submission.
- Proactively identify and resolve authorization barriers to prevent treatment delays for oncology patients.
- Coordinated peer-to-peer reviews between oncologists and insurance medical directors to overturn denials and achieve approvals.
- Facilitated appeals and reconsiderations through submission of clinical documentation and supporting literature to secure treatment approvals.
- Manage Formulary and oncology authorization requests for patients, immunotherapy, and supportive care agents.
- Monitored patient cases from initial request through final determination to ensure seamless continuity of care.
- Collaborate with infusion centers, pharmacy teams, and providers to coordinate timely chemotherapy administration.
UTILIZATION MANAGEMENT REPRESENTATIVE II
Elevance
Miami, FL
05.2023 - 11.2025
- Functioned as a Utilization Management Representative specializing in Behavioral Health, reviewing and processing authorization requests for mental health and substance use disorder services.
- Authorized initial and concurrent levels of care for behavioral health services based on established criteria.
- Managed prior authorizations, precertifications, and concurrent reviews, ensuring compliance with plan guidelines and regulatory requirements.
- Assessed eligibility, benefits, and coverage for behavioral health services, ensuring alignment with inpatient, outpatient, and intensive treatment program criteria.
- Executed clinical screening and applied payer-specific medical necessity criteria to effectively evaluate authorization requests.
- Referred complex or high-risk cases to clinical reviewers (RN/MD) for further determination.
PRECERTIFICATION AND AUTHORIZATION REP
Mayo Clinic
Rochester, MN
09.2021 - 07.2022
- Coordinated with insurance companies to secure pre-certifications/prior authorizations for scheduled patient services, facilitating access to care.
- Utilize appropriate strategies including online databases, electronic correspondence, and phone calls to obtain required pre-certifications and prior authorizations.
- Collaborated with patients, providers, and departments to gather all necessary information before scheduled services, enhancing service readiness.
- Communicate with patients, providers, and other departments regarding issues or problems in obtaining required pre-certifications/prior authorizations.
- Maintain knowledge of and comply with commercial and government payer requirements for obtaining pre-certifications/prior authorizations.
- Maintain knowledge of CMS requirements and guidelines, as provided by department leadership and/or training.
- Monitored accounts in assigned work queues, clearing them according to management guidelines to ensure timely processing.
- Maintain confidentiality of patients' financial and medical records.
SR. INSURANCE VERIFICATION - TEAM LEAD
University Of Miami
Miami, FL
01.2018 - 04.2021
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Obtained authorizations for both outpatient and inpatient surgeries.
- Requested authorizations across multiple specialties and platforms, streamlining the process for timely approvals.
- Communicated verification and authorization updates to departments, enhancing decision-making for patient admissions and insurance coverage.
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
- Completed administrative patient intakes, gathering case histories, insurance information, and mandated forms to ensure accurate patient records.
- Processed financial clearances for over 80 patients in a single day.
- Trained new staff on current, correct insurance verification procedures.
- Performed various administrative tasks by filing, copying and faxing documents.
Education
Associate of Science - Nursing
Santa Fe College
Gainesville, FL09-2028
High School Diploma -
Miami Sunset Sr High
Miami, FL 06-2002
Skills
- Oncology Case Management
- NCCN Guidelines Interpretation
- Medical Necessity Review
- Utilization review
- Appeals & Denial Management
- Peer-to-Peer Coordination
- Patient Care Coordination
- EPIC (Oncology Workflows)
- Cross Functional Team Collaboration
- Process Improvement & Turnaround Time Reduction
- Healthcare Policy Compliance
- Oncology Case Management
Languages
- English, Native or Bilingual
- Spanish, Native or Bilingual
Timeline
CASE MANAGER
University of Miami
11.2024 - Current
UTILIZATION MANAGEMENT REPRESENTATIVE II
Elevance
05.2023 - 11.2025
PRECERTIFICATION AND AUTHORIZATION REP
Mayo Clinic
09.2021 - 07.2022
SR. INSURANCE VERIFICATION - TEAM LEAD
University Of Miami
01.2018 - 04.2021
Associate of Science - Nursing
Santa Fe College
High School Diploma -
Miami Sunset Sr High