Allison Sylvester
Brandon,MS
Summary
Detail-oriented Prior Authorization & Medical Necessity Specialist proudly offering over fifteen years' experience managing medical documents meticulously. Polished professional known for working closely with insurance companies to alleviate denied claims and obtain necessary prior approvals for services. Multitasks expertly in fast-paced environments. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Knowledgeable Prior Authorization & Medical Necessity Specialist with solid foundation in specialized tasks and track record of delivering results through targeted initiatives. Proven ability to implement effective strategies that enhance operational efficiency and support team objectives. Demonstrated proficiency in problem-solving and project management.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Prior Authorization & Medical Necessity Specialist
Baptist Hospital
09.2017 - Current
- Communicates precertification information to all internal/external customers by fax, phone, or written report while working remote
- Apply knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations
- Verify each appointment scheduled for both medical necessity and prior authorization then work each patient account per state guidelines
- Transcribe orders in right fax and verify each test has an order
- Also, verify upcoming PET tests and make sure we have an authorization or re schedule patients as needed due to loss of money for the hospital
- Determine which party would be liable for payment on medical services by thoroughly reviewing patient insurance coverage/benefits
- Speak with nurse at doctor office via telephone or email to obtain correct ICD 10 code or an updated prior authorization in order to optimize reimbursement for the patient as well as health care providers
- Assist with medical review cases and clarify cases are approved or denied by health company standards
- Initiate and obtain prior authorization for outpatient radiology services
- Trained to back up medical necessity nurse when needed
- Daily use of HCPC (CPT) and ICD 10 codes to perform daily tasks
- Strive to reach and maintain department goals at the highest standard in all areas of responsibility, task, and patient satisfaction as set by Administration and Corporate expectation
- Performs duties in accordance with well-established rules, procedures, regulations, principles and operations covering patient medical records, their required contents, establishment and maintenance of special registries, documentation of incidents, and diagnostic coding requirements and procedures
- Remain up- to- date on various benefit plans, medical policies and state-specific clinical guidelines or criteria
- Communicates recommendations, clinical information, and fiscal information to appropriate internal and external customers in order to facilitate optimal delivery of services and customer satisfaction
- Trained in several departments and fill in for inpatient surgery, emergency room prior authorizations as well as cardiac rehab as needed
- Certified trainer in Epic
- Train new employee on job procedures and duties, back up prior authorization team as needed
- Participated several times in peer-to-peer interviews for employee new hires
- Carried on prior authorization role alone for several months and achieved day-to-day workflow as well as met all standards
- Take initiative to assist other departments in hospital verification process.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Assisted in managing electronic health records, ensuring data accuracy and compliance with regulations.
- Supported interdisciplinary teams in developing care plans, fostering collaboration among healthcare professionals.
- Conducted training sessions for new staff on hospital policies and systems, promoting knowledge sharing.
- Analyzed patient feedback to identify service gaps, contributing to quality improvement initiatives.
- Facilitated communication between departments, enhancing operational efficiency and team collaboration.
- Followed all company policies and procedures to deliver quality work.
- Collaborated with cross-functional teams to achieve project goals on time and within budget.
- Implemented new training programs for staff, leading to higher employee retention rates and better overall performance.
- Developed training materials to enhance staff proficiency and productivity.
Patient Access Representative
METHODIST HEALTH SYSTEMS
05.2012 - 09.2017
- Relays information between patients and other staff members, and provides them with updates as needed
- Prioritizes the order of care so that the most critical patients are seen first
- Schedule Patients for Diagnostic Exams and Procedures for outpatient
- Obtains and/or updates verification of benefits and/or pre-certification for applicable tests and/or procedures
- Maximizes reimbursement for services rendered by appropriately identifying insurance carrier, benefits Insurance Verification
- Applied HIPAA privacy and security regulations while handling patient information.
- Obtained necessary signatures for privacy laws and consent for treatment.
- Process Requests and Filing of Patient Records
- Recognized in Press Ganey three times for outstanding customer service
- Works with clinical staff and social work to admit behavioral health patients
- Train new employees
- Assists patients in understanding financial obligations, collects copayments, self-pay deposits, and patient balances to reduce Accounts Receivable
- Verified demographics and insurance information to register patients in computer system.
Patient Access Representative
TEXAS HEALTH RESOURCES
01.2006 - 05.2012
- Accurately gathers complete financial and demographic information to ensure medical records/billing process flows efficiently
- Obtains and/or updates verification of benefits and/or pre-certification for applicable tests and/or procedures
- Prepares, presents, and thoroughly explains applicable legal, ethical, and compliance documents; ensures proper consents are signed by the appropriate parties
- Maximizes reimbursement for services rendered by appropriately identifying insurance carrier, benefits, etc
- Processed patient responsibility estimate determined by insurance at pre-registration.
- Updated reference materials with Medicare, Medicaid and third-party payer requirements, guidelines, policies and list of accepted insurance plans.
- Optimized provider time and treatment room utilization with appropriate appointment scheduling.
- Prevents denials by ensuring timely notification of admission to insurance carriers
- Assists patients in understanding financial obligations; collects co-payments, self-pay deposits, and patient balances to reduce Accounts Receivable
- Stays abreast of and complies with applicable regulations, entity and/or system policies and procedures
- Maintains customer service and/or productivity guidelines set forth by applicable leadership
- Worked in Trauma center to register patients
- Completes other duties as assigned
- Became CHAA certified and recognized twice in Press Ganey for excellent patient satisfaction.
- Applied HIPAA privacy and security regulations while handling patient information.
- Organized and maintained records by updating and obtaining both personal and financial information from patients.
- Coordinated patient scheduling and registration processes to enhance operational efficiency.
- Verified insurance eligibility and benefits, ensuring accurate patient data collection.
- Assisted patients with inquiries, providing exceptional customer service and support.
- Managed patient flow to minimize wait times and improve overall satisfaction.
- Collaborated with clinical staff to streamline communication regarding patient needs.
- Utilized electronic health record systems for accurate documentation and information retrieval.
- Trained new team members on procedures and best practices for patient access operations.
- Stayed calm under pressure to and successfully dealt with difficult situations.
- Contributed to a positive work environment by fostering strong relationships among colleagues, promoting teamwork, and sharing best practices.
Membership Specialist/Customer Service Specialist
Blue Cross Blue Shield
12.2001 - 01.2006
- Worked with highly confidential information to administer benefits records for state employees
- Corresponded with state agencies and executives regarding benefit plans and changes to state health plan insurance.
- Enrolled employees for health insurance and assisted employees with any necessary changes
- Followed state laws and regulations to ensure accuracy
- Submitted payroll correspondence
- Worked with TTY phone to correspond with deaf state employees.
- Managed customer conflicts and challenging situations by staying calm and accessing internal knowledge bases to develop strategic solutions.
- Helped members resolve account problems and navigate internal systems to handle routine needs.
- Offered exceptional customer service to differentiate and promote company brand.
- Increased customer acquisitions by 75% through effective social media management, grassroots marketing, and new member orientation.
- Provided exceptional customer service, addressing inquiries and resolving issues efficiently.
- Collaborated with cross-functional teams to enhance member experience and streamline operations.
- Assisted in the development of educational materials for members regarding benefits and services.
Education
Associates Degree - Business
Hinds Community College
Raymond, Mississippi1994
High School Diploma -
Clinton High School
Clinton, MS06.1990
Skills
- Dependable and punctual
- Proficient in Microsoft Office, Excel, Power Point
- Multitasking
- Official Epic Trainer
- Quickly adjusts to change
- Stay calm in high-pressure situations
- Perform duties independently
- CHAA Certified & HIPAA Trained
- Efficient learner
- Daily use of ICD 10 and CPT codes
- Versatile in various departmental roles
- Detailed documentation
- Creative Problem Solving
- Proficient in collaborative teamwork
- Extensive medical terminology knowledge
Accomplishments
CHAA certified since 2013
Mentioned in Press Ganey several times for outstanding customer service by patients
Certification
Epic certified trainer
CHAA certification
Timeline
Prior Authorization & Medical Necessity Specialist
Baptist Hospital
09.2017 - Current
Patient Access Representative
METHODIST HEALTH SYSTEMS
05.2012 - 09.2017
Patient Access Representative
TEXAS HEALTH RESOURCES
01.2006 - 05.2012
Membership Specialist/Customer Service Specialist
Blue Cross Blue Shield
12.2001 - 01.2006
Associates Degree - Business
Hinds Community College
High School Diploma -
Clinton High School
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