Sushmitha Sushma
Results-driven healthcare RCM professional with 3 years of experience in prior authorization, referral management, and hospital billing and physician billing operations.
About
Results-driven healthcare RCM professional with 3 years of experience in prior authorization, referral management, and hospital billing and physician billing operations. Proven expertise across Radiation Oncology, Radiology, Pathology, DME, and E&M services, including TAR processing, retro and concurrent authorizations. Adept at payer communication, medical necessity review, and ensuring clean claims through strict compliance with payer and HIPAA standards.
Experience
Senior AR Executive - NYX Medical solution
(2025-06 - 2026-06)
- Handled end-to-end prior authorization and referral management for Therapy Authorization Skills (PT / OT / ST)
- Insurance & Payer Authorization
- Prior Authorization & Pre-Certification Processing
- Insurance Verification (Commercial, Medicare, Medicaid)
- Authorization Submission for PT, OT, and ST Services
- Knowledge of CPT Codes (e.g., 97110, 97530, 92507)
- ICD-10 Diagnosis Code Validation
- Medical Necessity Documentation Review
- Benefits & Eligibility Verification
- Treatment Plan Review & Authorization Alignment
- Plan of Care (POC) Tracking
- Timely Authorization Renewal & Extensions
- Compliance with Medicare Guidelines
- HIPAA Compliance
- Coordination with Referring Physicians
- Electronic Medical Records (EMR/EHR)
- Experience with systems like Epic, WebPT, or Cerner
- Insurance Portal Submissions
- Tracking Authorization Expiration Dates
- Processed and managed prior authorizations for PT, OT, and Speech Therapy services across multiple insurance providers
- Verified insurance benefits and ensured accurate CPT and ICD-10 coding for therapy services
- Reduced authorization-related claim denials by proactively tracking renewals and documentation compliance
- Coordinated with therapists and physicians to obtain required documentation for medical necessity approvals
- Managed high-volume authorization requests while maintaining HIPAA compliance
Authorization specialist - Omega healthcare - Bangalore - Bangalore
(2023-02 - 2025-06)
- Handled end-to-end prior authorization and referral management for multiple specialties including Radiology, Pathology, Radiation Oncology, DME (Durable Medical Equipment), and E&M services
- Performed medical necessity evaluation by reviewing clinical documentation, diagnosis codes (ICD-10), procedure codes (CPT), and payer-specific authorization guidelines
- Managed high-volume authorizations (100+ per week) for diagnostic imaging, oncology treatments, laboratory services, and physician office visits with <5% error rate
- Coordinated with providers, radiology centers, pathology labs, oncology departments, and DME vendors to obtain complete and accurate clinical records
- Verified insurance eligibility, benefits, and authorization requirements across commercial and government payers
- Followed up on pending, denied, and partially approved authorizations, ensuring resolution within SLA and improving claim success rates
- Worked closely with billing and RCM teams to ensure authorization-to-claim accuracy, reducing downstream denials
Education
S.S.L.C - Karnataka Secondary Education Board (2017 - 2017)
P.U.C - Pre-university Board, Karnataka (2019 - 2019)
B.com - Commerce - Banglore university (2022 - 2022)
