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Skills

  • Budgets
  • Prescription Coordination
  • Pharmacology
  • Data analysis
  • Project organization
  • Patient confidentiality
  • Payment collection
  • Claims Dispute Resolution
  • Benefit Coverage
  • Business operations

Work Experiences

  • Compressed approval times from several months to category.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Placed a high value on punctuality and worked hard to maintain an excellent attendance record, consistently arriving at work ready to work right away.
  • Had an excellent attendance record and was always on time for work.
  • Ensured that patient privacy and security regulations, such as Six Sigma, were followed.
  • Advised providers on optimizing treatment documentation to align with payor policies, reducing claim denials by 2 cases per month.
  • Wrote and distributed denial letters outlining the reasons for the denial as well as possible appeal options.
  • Achieved a 35% reduction in errors.
  • Automated prior authorization documentation.
  • Consistently exceeded quality assurance benchmarks.

Summaries

  • Achieved a 53% reduction in processing times.
  • With exceptional knowledge of vendor management, talented at data entry and analysis.
  • Costs were consistently reduced while profits were increased.
  • Dedicated to following the medical funding guidelines and policies that have been established.
  • Adept at creating efficient workflows and leveraging technology to cut prior authorization processing times in half through smart process automation.
  • Achieved 58% compliance with regulatory requirements.
  • Accomplished in training and mentoring staff on insurance policies and prior authorization procedures, reducing team errors by 58% and enhancing accuracy.
  • Conducted diligent documentation review.
  • Strengths in stakeholder engagement and cross-functional collaboration backed up by Pharmacy training.
  • Maintains a sympathetic and compassionate relationship with customers.

Accomplishments

  • Resolved product issue through consumer testing.
  • Simplified complex insurance verification procedures, leading to a 59% improvement in first-pass approval rates.
  • Successfully handled over 7 oncology prior authorization cases, preventing revenue losses of 9 in 2023.
  • Collaborated with physicians and insurance providers to secure approvals for expedited cases, reducing patient wait times by 12 hours.
  • Documented and resolved system which led to standard.
  • Processed 5 prescriptions for high-cost specialty drugs, with an accuracy rate of 18%.
  • Implemented tailored workflows for specialty drug authorizations, reducing processing times by 2 days and improving patient outcomes.
  • Worked closely with medical billing specialists to align on coding compliance, ensuring smooth processing of prior authorizations and minimizing delays.
  • Regularly monitored and updated payer documentation guidelines, ensuring all prior authorization submissions met compliance standards.
  • Consistently met productivity benchmarks, processing 11 authorizations per day with a 76% first-pass success rate.

Affiliations

  • Association for Supply Chain Management (APICS)
  • Academy of Managed Care Pharmacy (AMCP)
  • American Pharmacists Association (APhA)
  • Toastmasters
  • National Council for Prescription Drug Programs (NCPDP)
  • Certified Prior Authorization Specialist (CPAS)
  • National Association of Insurance Commissioners (NAIC)
  • National Healthcareer Association (NHA)
  • Rotary International
  • Project Management Institute

Certifications

  • Certified Medical Reimbursement Specialist (CMRS)
  • Certified Specialist in Managed Care Pharmacy (CSMCP) - Ironclad Systems
  • Certified Specialist Managed Care (CSMC)
  • Certified Pharmacy Benefits Specialist (CPBS)
  • Certified HIPAA Professional (CHP) - Lakeside Partners
  • Certified Healthcare Access Associate (CHAA)
  • Certified Managed Care Professional (CMCP)
  • Certified Pharmacy Technician (CPhT) - Northwind
  • Certified in Healthcare Privacy and Security (CHPS)
  • Certified Business Analysis Professional (CBAP)

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