Elysia V. Espiritu
Remote healthcare professional with 5 years of experience in insurance verification, medical claims processing, prior authorization, referral coordination, and patient scheduling.
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About
Remote healthcare professional with 5 years of experience in insurance verification, medical claims processing, prior authorization, referral coordination, and patient scheduling. Proficient in EPIC and eClinicalWorks (eCW), with a strong track record of managing end-to-end administrative workflows, insurance follow-ups, and provider coordination. Highly detail-oriented, HIPAA-compliant, and effective in fast-paced virtual environments, with strong communication and time-management skills that support timely patient access to care.
Experience
Scheduling and Referral Coordinator - VIRTUAL MEDICAL ASSISTANT
(2025-08 - 2026-01)
- Schedule, reschedule, and confirm patient appointments across multiple providers and departments
- Process incoming and outgoing referrals, ensuring all required documentation and authorizations are complete
- Communicate with patients regarding appointment details, referral status, and next steps
- Coordinate with providers, clinics, and insurance companies to verify referral requirements and eligibility
- Track and follow up on pending referrals, authorizations, and appointment confirmations.
- Handle inbound and outbound calls professionally and efficiently
- Address scheduling conflicts, cancellations, and urgent appointment needs
- Ensure compliance with HIPAA and organizational policies
Medical Claims Analyst / Insurance Verification & Prior Authorization Representative - MED-METRIX INTERNATIONAL PH-II
(2023-01 - 2025-07)
Consistently recognized as one of the top-performing associates for 2024 based on quality scores, productivity metrics, and accuracy in claim processing and prior authorizations. Trusted as a go-to backup specialist for handling complex, high-impact prior authorization cases—including oncology treatments, prescription drug approvals, radiology procedures, and cases requiring deep medical necessity analysis.
- Audited and repriced medical claims in alignment with Medicare and hospital-specific reimbursement schedules using EPIC.
- Verified insurance eligibility and coverage for scheduled procedures, ensuring accuracy in benefits and reducing claim denials.
- Collaborated with providers and insurance representatives to resolve coverage issues, support appeals, and obtain clinical documentation.
- Managed the full prior authorization process: reviewing diagnoses and treatment plans, completing forms, and submitting to payors.
- Initiated and followed up on peer-to-peer reviews and PCP referral requests to ensure timely patient access to care.
- Maintained a consistent record of exceeding team benchmarks for turnaround time, accuracy, and documentation quality.
- Contacted insurance companies to appeal and overturn denied claims by providing additional documentation, clarifying medical necessity, and correcting billing errors.
- Actively followed up on claims with pending statuses to ensure timely resolution and reimbursement, maintaining consistent communication with insurance representatives.
- Resubmitted corrected claims in alignment with payor-specific guidelines to reduce rejections and improve collection rates.
- Handled Workers' Compensation accounts, serving as the primary liaison with claims adjudicators to validate claim status, address discrepancies, and coordinate resolution.
- Utilized the EPIC system to track claim progress, document interactions, and maintain up-to-date case records.
Senior Collection Representative - NTT DATA GROUP INC.
(2022-03 - 2023-01)
- Contacted insurance companies to appeal and overturn denied claims by providing additional documentation, clarifying medical necessity, and correcting billing errors.
- Actively followed up on claims with pending statuses to ensure timely resolution and reimbursement, maintaining consistent communication with insurance representatives.
- Resubmitted corrected claims in alignment with payor-specific guidelines to reduce rejections and improve collection rates.
- Handled Workers' Compensation accounts, serving as the primary liaison with claims adjudicators to validate claim status, address discrepancies, and coordinate resolution.
- Utilized the EPIC system to track claim progress, document interactions, and maintain up-to-date case records.
Customer Service Representative - CONCENTRIX
(2020-09 - 2022-03)
- Handled inbound calls for member services, assisting clients with insurance updates, premium payments, and policy inquiries.
- Processed requests for durable medical equipment (DME), including initiating appeals and addressing grievances.
- Provided accurate and empathetic support to members, ensuring high-quality service in accordance with healthcare compliance standards
Nursing Aide - SALVE REGINA HOSPITAL
(2018-10 - 2020-01)
- Provided direct patient care including monitoring vital signs and administering prescribed oral medications.
- Assisted patients with daily living activities such as hygiene, mobility, and feeding.
- Supported medical staff in delivering quality healthcare services.
Education
Bachelor of Science in Nursing - Nursing - Arellano University - Andres Bonifacio Campus (2016 - 2019)
Rizal High School (2012 - 2015)
Palatiw Elementary School (2006 - 2012)
