Sushmitha Sushma

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.

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

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)