Priscilla Hernandez

Healthcare professional with 10+ years of Utilization Review experience managing insurance authorizations, concurrent reviews, payer communication, medical necessity requirements, and clinical documentation. Experienced in navigating payer guidelines, managing high-volume caseloads, tracking authorization timelines, and collaborating with clinical teams to support timely access to medically necessary care. Strong background coordinating complex, time-sensitive cases and maintaining clear communication across clinical, administrative, and insurance teams.

Utilization Review Coordinator - Restore Health & Wellness Center

(2023-01 - 2026-01)

• Managed utilization review and authorization processes while ensuring timely communication with insurance payers and clinical teams.
• Coordinated initial and concurrent reviews with commercial insurance payers to obtain and maintain treatment authorizations.
• Reviewed clinical documentation for medical necessity and identified information needed to support authorization and continued-stay requests.
• Tracked authorization dates, review deadlines, approved units/days, and payer determinations to prevent gaps in coverage.
• Collaborated with clinical teams to obtain documentation required for timely insurance reviews.
• Communicated with insurance companies regarding case status, additional clinical requests, authorizations, and coverage determinations.

Utilization Review Specialist - Crestview Recovery

(2017-01 - 2023-01)

• Managed approximately 15+ utilization review cases daily while coordinating clinical documentation and insurance requirements.
• Completed initial and concurrent reviews and communicated clinical information to commercial insurance payers.
• Reviewed patient documentation to ensure information supported medical necessity and payer requirements.
• Maintained authorization records and monitored review dates, approved days, and payer deadlines.
• Collaborated with clinical teams to address documentation needs and payer requests.
• Assisted with complex and time-sensitive cases to minimize authorization delays and interruptions in coverage.

Utilization Review Manager - Recovery First

(2014-01 - 2017-01)

• Managed utilization review operations while maintaining a caseload of approximately 12-15 cases daily.
• Oversaw authorization tracking, concurrent review processes, payer communication, and daily UR workflow.
• Developed and maintained tracking systems to monitor authorization dates, review deadlines, and payer determinations.
• Collaborated with clinical teams to improve documentation quality and strengthen medical necessity support.
• Assisted with escalated insurance cases, authorization barriers, and denial-related issues.
• Supported process improvements designed to increase efficiency, timely reviews, and continuity of care.