Danielle

Prior Authorization and Healthcare Operations professional with over 5 years of experience supporting prior authorization, intake/referral, medical claims, and insurance verification workflows. Experienced in creating and processing 40–60 inpatient and outpatient authorization cases daily, reviewing provider submissions, verifying benefits and eligibility, and ensuring required clinical documentation is complete. Knowledgeable in IPA delegation, DOFR guidelines, Medicare and Medicaid, appeals and denials research, HIPAA compliance, and coordinating with providers and health plans to support timely patient care.

Proficient in Epic and other EMR/CRM systems, Microsoft Office, fax-based authorization workflows, medical terminology, and high-volume inbound and outbound provider support.

Prior Authorization Specialist - Evolent Health - Remote

(2024-03)

• Processed, shelled/ created prior authorization for Inpatient/ outpatient services and sending, receiving prior authorization through faxes to providers or members.
• Answer coverage questions including verifying benefits & eligibility, claim questions, prior authorization Information.
• Manage prior authorization requests by reviewing provider submissions and ensuring required clinical documentation is complete.
• Verified IPA delegation and DOFRS guidelines when needed and coordinated with providers and health plans, and validated authorization requirements to ensure compliance, accurate financial responsibility, and timely patient care without delays.
• Utilized Epic EMR to review patient records, verify insurance eligibility, and support prior authorization workflows.
• Communicate with providers, facilities, and insurance carriers to obtain additional documentation and resolve authorization issues.
• Worked within APeX to manage work queues, update patient information, process referrals, and coordinate authorization requests with providers and payers.
• Verify member eligibility, benefits, and coverage requirements to support authorization determinations.
• Maintain detailed case documentation and authorization notes while monitoring pending requests and followups.
• Handle high-volume inbound and outbound calls assisting providers with authorization status and requirements.
• Manage an average of 40–60 authorization cases daily while meeting service level agreements and turnaround time metrics.
• Assist providers with authorization denials and next-step guidance for reconsiderations or appeal submissions.
• Review case documentation and claim details to identify potential appeal opportunities and escalate cases when appropriate.
• Ensure compliance with HIPAA regulations and internal healthcare policies when handling protected health information.

Intake/ Referral Specialist - Acelis Connect Health - Remote

(2023-08 - 2024-03)

• Processed prior authorization for procedures and sending and receiving prior authorization through faxes to providers or members.
• Review and process medical claims for Medicare, Medicaid, and commercial insurance plans ensuring accuracy and compliance.
• Verified Independent Practice Association (IPA) delegation and DOFRS guidelines to ensure accurate authorization processes.
• Investigate denied or rejected claims and coordinate with providers and insurance carriers to resolve discrepancies.
• Verify patient eligibility, benefits, and coverage prior to claim submission.
• Maintain detailed claim documentation and assist with appeals preparation and claim corrections.

Customer Service Associate - H&H Call Center - Remote

(2021-01 - 2023-08)

• Verified Independent Practice Association (IPA) delegation and DOFRS guidelines to ensure accurate authorization processes.
• Processed prior authorizations, medical claims and reimbursement requests while ensuring compliance with ICD-10, CPT, and HCPCS coding standards.
• Resolve billing discrepancies by communicating with insurance carriers and provider offices regarding claim status.
• Educate patients on insurance coverage, deductibles, co-payments, and Explanation of Benefits (EOBs).
• Manage high volumes of billing inquiries and claim follow-ups while maintaining accurate documentation.
• Ensure compliance with HIPAA regulations and internal healthcare policies when handling protected health information.

Associate degree - University of Phoenix (2021-06)