As a Medical Prior Authorization Specialist, my role is to review and manage requests for approval of medical treatments, procedures, or medications before they are provided to patients. I ensure that each request meets the medical necessity criteria and aligns with the guidelines set by insurance companies. I work closely with healthcare providers, insurance companies, and patients to gather the necessary documentation, submit authorization requests, and follow up to ensure timely approval. I also analyze treatment plans for compliance with insurance policies, identify potential issues, and resolve any delays in the process. My goal is to help ensure that patients receive timely access to the care they need, while also ensuring the treatments are medically appropriate and cost-effective.

In my role at Extraordinary Conceptions, I monitored medical claims for clients, working closely with both clients and medical offices to ensure accurate claim processing across various insurance plans. I managed payments on medical bills, while also ensuring compliance with contractual obligations. I coordinated with clients to find in-network providers and addressed complex issues like dual insurance coordination and self-pay discount negotiations to ensure smooth claims processing. Additionally, I audited insurance summaries to verify the accuracy of medical bill processing and negotiated denied claims. I consistently multitasked in a high-volume environment, increasing productivity by 10%.

In my remote role at PrimeSurro, I was responsible for reviewing surrogacy applications to assess whether potential candidates were suitable emotionally, medically, financially, and socially. I conducted interviews, critically evaluated applications, and asked targeted questions based on the information provided by the applicants. I also managed the process of requesting, reviewing, and retrieving medical records for surrogacy candidates, ensuring each applicant had a 55%-100% chance of being approved by an IVF clinic. Additionally, I wrote, maintained, and updated the Standard Operating Procedures (SOPs) for the Intake Department and played a key role in updating procedures for the Recruiter Department. I helped train recruiters to better understand the surrogacy process, empowering them to educate and guide potential surrogates through the process.

In my role at Extraordinary Conceptions, I managed the request and retrieval of over 800 medical records from healthcare facilities worldwide, ensuring compliance with company, state, and federal regulations. I conducted initial medical risk assessments for all applicants, helping achieve a 75% acceptance rate for surrogates during clinic reviews. I also assisted applicants in locating and securing relevant medical records, including those from military bases around the globe. As the primary point of contact for records management, I developed and implemented policies to streamline processes, including the introduction of electronic medical record retrieval, which boosted productivity by 45%. I also wrote, maintained, and updated the Standard Operating Procedures (SOPs) for the Medical Records Department and trained new staff on efficient record request processes, resulting in a 12% increase in team productivity.