Cecilia Prado
San Ysidro
Summary
Results oriented professional with substantial experience in various project management Organized professional knowledgeable in regulatory standards and compliance requirements. Confident Prior Authorization Specialist with a background spent working in medical offices, communicating effectively orally and through writing and developing prior authorization workflows.
Overview
17
17
years of professional experience
Work History
Referral/Prior Authorization Specialist
San Diego PACE, San Ysidro Health
2017.06 - Current
- Remote collaboration skills
- Receive and processes authorizations in a timely manner with attention to quality, accuracy, and completeness of work
- Entered CPT,ICD10,HCPCS codes into EHR as requested and updated
- Responsible for onboarding and developing training for new team members
- Schedule requests for referrals and treatment authorizations
- Obtain authorization requests from various in network specialists via phone, in writing or email/fax, adjusting effectively to organizational changes
- Follows-up on missing documentation to obtain authorization when appropriate
- Schedule appointments for specialty care, special studies, Durable Medical Equipment (DME) or other ancillary services as requested by the primary care physician
- Coordinate care within the guidelines of health plan, contracts.
- Uses various modules of the computer system to obtain information, schedule appointments, query information and obtain authorizations
- Respond to inquiries as to statuses of authorizations by assessing the request and evaluating the circumstances to provide regular, consistent, timely, and meaningful information to our patients
- Seeks different points of view and leverages diverse perspectives
- uploaded authorization and clinical notes in EHR system Truchart
- Update referrals with the date and time of appointments
- assisted supervisor with established departmental policies and procedures
- Working at different sites/locations is required based on business and staffing needs or for trainings as deemed necessary
- Attends meetings as required and participates in committees as directed; works cooperatively with others to meet shared objectives
- Use a solutions-based approach to help improve processes and workflows
- Responsible for timely processing, documenting, and follow up of referrals and authorizations, as requested by the primary physician
- Knowledge of basic medical terminology
- Serve as the main point of contact for providers and clinic staff, regarding referrals, authorizations and appointment scheduling
- Receives and processes referrals and approvals in a timely manner from ALL PACE locations
- Process the urgent and authorizations/referrals for their assigned PACE location
- Ensures that external providers receive authorizations by calling, emailing and or faxing
- Verify via phone that the requested external provider is within our network.
- Initiate process of Letter of agreements with out of network specialists when approved by PCP by verifying PCP NPI Tax ID-business information
- Gather all the necessary information on external provider, to proceed with authorization
- Sends Authorization Approval Letter to participant via mail
- Send notice to SW when Authorization Letter is sent back for incorrect address
- Uses various modules of the computer system to obtain information, schedule appointments, query information and process authorizations
- Ensure all appointments are scheduled appropriately and according to participant needs and care plan specifications
- Assures all necessary appointment records are maintained according to policy
- Properly documents in electronic health record, all appointments, communication, and relevant information regarding participants’ appointments, follow ups, companionship, translation and transportation needs
- Coordinate with the transportation team when there is a need to request last minute transportation
- Provides translation, verbal or written as necessary, if bilingual
- Works in Services Coordination with other disciplines & patients as needed
- Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy
- Shares accountability for overall patient health outcomes, working in coordination with Care Teams
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Tracked referral submission during facilitation of prior authorization issuance.
- Developed and maintained productive working relationships with healthcare providers.
- Interviewed applicants and explained scope of different available benefits.
- Reviewed applications for different aid programs and determined which qualification criteria for individuals.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
Clinical Office Assistant/HCHP Case Management
La Clinica De La Raza Transit Village Dental
2015.06 - 2016.08
- 1st point of contact for patients and processing check in for appointments
- Retrieved and entered data into medical records system. Next Gen
- Received and routed messages or documents such as laboratory results to appropriate staff.
- Managed mail sorting, filing and photocopying.
- Determined source of payment by verifying program eligibility with insurance plans.
- Collected payment for services rendered, operated cash register and maintained accurate till.
- Coordinated patient scheduling, check-in, check-out and payments for billing.
- Checked insurance eligibility and notified of any copayments due
- Adhered to strict HIPAA guidelines to protect patient privacy.
- Provided prompt, polite and professional in-person and telephone customer service.
- Updated patient information and insurance details for accurate electronic medical records.
- Prepared patient charts by gathering and organizing medical records ahead of appointments.
- Registered patients and completed associated paperwork for accurate records.
- Gathered forms and copied insurance cards to collect patient information for billing and insurance filing.
- Managed office logistics by scheduling appointments, maintaining files and collecting payments.
- Greeted visitors and initiated triage processes for clients to streamline patient flow.
- Assisted with medical coding and billing tasks.
- Maintained calendar and modified scheduling as needed by Doctors
- Data entry and updating patients records
- Assisted Physicians and clinical staff with candidate interviews
- Performed detailed administrative work methodically with speed and accuracy
- Managed a caseload and maintained calendar of 15+ patients in Homeless Program providing free Dental Services and helped advocate for community resources available
- Provided monthly audit reports and verified medical eligibility
- Multitasked coverage of multiple phone lines while attending clients
- Provided clients with referrals and resources throughout the community
- Communicate and work congenially with people from various ethnic, socio-economic, and educational background and life experience
- Maintained a calm professional composure in hostile situations
Security
Cybernet Entertainment, The Armory
2014.08 - 2016.02
- Complex problem solving and implement solutions
- Patrol Industrial premises to prevent and detect intrusion
- Maintain relevant logs and records of incidents occurred
- Maintain Vigilant awareness at all times
- Strong public communication skills
- Team player, work with Security teams of 5 or more
- Ensure security of gates, doors, and monitor metal detectors
- Greeted guests professionally and courteously to cultivate welcoming atmosphere while making safety top priority.
- Remained calm, assertive, and mindful to think critically and problem solve during stressful situations.
- Notify law enforcement in case of emergency.
- Conducted training sessions for new security personnel to facilitate compliance with security protocols.
- Operated handheld metal detector and other surveillance devices to screen individuals entering facility.
- Patrolled internal building spaces and facility grounds to identify and deter threats to assets.
- Monitored CCTV cameras and alarm systems for security breaches.
- Communicated with security team and building supervisors using two-way radios, mobile phones and other technological devices.
- Interacted assertively but non-confrontationally with personnel and general public.
Human Resources Assistant
Farmers Insurance
2015.01 - 2015.03
- Sourcing candidates and screening resumes through existing talent pool
- Helped employees register for benefits programs using online portals.
- Checked references for potential candidates.
- Assisted with creating employee handbooks and manuals.
- Maintained calendar for interviews on a daily basis
- Placed numerous calls to potential employees for interviews and answered any questions
- Reported daily calls at the end of shift.
- Filed paperwork, sorted, and delivered mail and maintained office organization.
- Conducted new hire orientation to verify completion of appropriate paperwork, recording information on human resources database.
- Answered and redirected incoming phone calls for office.
- Screened applicant resumes and coordinated both phone and in-person interviews.
- Delivered friendly assistance with new hires throughout interviewing and hiring process.
Shift leader
Wing Fiesta
2014.09 - 2015.01
- Provided direct supervision to employees to ensure business operated correctly
- Line cook and food prep when needed
- Notified supervisor of schedule changes and adjusted work calendar as needed
- Cashier, verified monies at the end of shift of employees
- Made deposits and exchanges at the bank when needed.
- Trained new employees and delegated daily tasks and responsibilities.
- Resolved customer complaints and issues and offered thoughtful solutions to maintain customer satisfaction.
- Managed shift operations, supplied resources and monitored team performance to keep business profitable and running smoothly.
- Maintained clean and well-organized production areas to avoid violations or unnecessary work delays due to hazards or inefficient layouts.
- Completed cash and credit card transactions accurately using POS software.
Office Specialist / Temp Case Manager
Yakima County Probation Department
2006.06 - 2013.11
- Processed intakes following court in a one on one setting, informed clients about their court ordered obligations
- Notified law enforcement of outstanding warrants
- Maintained calendars and scheduled appointments for Probation officers and Case Managers
- Monitored court ordered obligations of low risk adult offenders
- Provided clerical support to company employees by copying, faxing, and filing documents.
- Responded to inquiries from callers seeking information.
- Provided monthly audit reports, and conducted monthly criminal history checks for Probation Officers
- Cash handling and payments processing, counted and verified money at the end of shift
- Processed legal documents within probation databases; Cayenta, ICM, LawBase, and JIS
- Managed daily data entry and kept clerical information accurate and up-to-date.
- Recorded phone prompts for Department phone tree
- Coordinated communication between clients and Probation Officers, Case managers
- Prepared legal documentation for various courts (Revocation Petitions, Memos & Terminations)
- Maintained strict confidentiality with clients
- Entered monthly compliance reports for clients from treatment centers and notified Probation Officers and Case Managers of clients out of compliance.
- Assisted clients in navigating housing, legal services and public benefits to gain access to valuable resources.
- Monitored clients' progress and tracked client services to provide crisis interventions.
- Developed and implemented comprehensive case management plans to address client needs and goals.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Monitored defendants' compliance and progress in treatment by reviewing reports from counseling agencies.
- Completed reports on behalf of court and associated legal entities.
- Wrote progress reports and testified under oath at court hearings.
- Maintained compliance with all legal statutes, policies and procedures.
- Referred misdemeanor offenders to necessary community resources.
Education
No Degree - Criminal Justice
Yakima Community College
Yakima Wa01.2013
High School Diploma -
Sunnyside High School
Sunnyside WA01.2005
Skills
- Typing (60+ wpm)
- Social Perceptiveness
- Customer Service
- Document Processing/Data Entry
- Administrative Support
- Cash Handling
- Bilingual
- Appointment Scheduling
- Recruiting
- Flexibility adapts to change
- Self Motivated
- Active collaboration
- Strong work ethic
- Deadline Driven
- Medical Coding
- Data Entry
- Retro-Authorizations
- Patient Referrals
- Authorizations
- Understanding of Medical Terms
- Physician Order Verification
- Knowledgeable in TruChart, NextGen, Epic, Word, Excel, Power point
- Billing Procedures
- Understanding of Insurance Details
- Benefit Coverage
- Insurance Procedures
- Patient Scheduling
- Medical Terminology
- Effective Communication Skills
- Records Maintenance
- Issue Research
Languages
Spanish
Bilingual or Proficient (C2)
English
Bilingual or Proficient (C2)
Timeline
Referral/Prior Authorization Specialist
San Diego PACE, San Ysidro Health
2017.06 - Current
Clinical Office Assistant/HCHP Case Management
La Clinica De La Raza Transit Village Dental
2015.06 - 2016.08
Human Resources Assistant
Farmers Insurance
2015.01 - 2015.03
Shift leader
Wing Fiesta
2014.09 - 2015.01
Security
Cybernet Entertainment, The Armory
2014.08 - 2016.02
Office Specialist / Temp Case Manager
Yakima County Probation Department
2006.06 - 2013.11
No Degree - Criminal Justice
Yakima Community College
High School Diploma -
Sunnyside High School
References
Upon Request
References
Upon Request
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