Danielle Christian Stallworth
Evolent Health
Richmond
6
years of professional experience
Healthcare revenue cycle and prior authorization professional with over 5 years of experience supporting prior authorization, intake/referral, medical claims, insurance verification, denials research, and appeals 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, Apex, EMR/CRM systems, Microsoft Office, fax-based authorization workflows, medical terminology, and high-volume inbound and outbound provider support.
Work History
Prior Authorization Specialist
2 Years 5 Months- Processed, shelled, and created prior authorizations for inpatient and outpatient services, including sending and receiving authorization documentation through fax.
- Answered coverage and claim questions by verifying benefits, eligibility, and prior authorization requirements.
- Managed prior authorization requests by reviewing provider submissions and ensuring required clinical documentation was complete.
- Verified IPA delegation and DOFR guidelines and coordinated with providers and health plans to validate authorization requirements, financial responsibility, and timely patient care.
- Utilized Epic EMR to review patient records, verify insurance eligibility, and support prior authorization workflows.
- Communicated 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.
- Verified member eligibility, benefits, and coverage requirements to support authorization determinations.
- Maintained detailed case documentation and authorization notes while monitoring pending requests and follow-ups.
- Handled high-volume inbound and outbound calls assisting providers with authorization status and requirements.
- Managed an average of 40–60 authorization cases daily while meeting service-level agreements and turnaround-time metrics.
- Assisted providers with authorization denials and next-step guidance for reconsiderations or appeal submissions.
- Reviewed case documentation and claim details to identify potential appeal opportunities and escalated cases when appropriate.
- Ensured compliance with HIPAA regulations and internal healthcare policies when handling protected health information.
Intake/Referral Specialist
7 Months- Processed prior authorizations for procedures and sent and received authorization documentation through fax.
- Reviewed and processed medical claims for Medicare, Medicaid, and commercial insurance plans, ensuring accuracy and compliance.
- Verified IPA delegation and DOFR guidelines to support accurate authorization processes.
- Investigated denied or rejected claims and coordinated with providers and insurance carriers to resolve discrepancies.
- Verified patient eligibility, benefits, and coverage prior to claim submission.
- Maintained detailed claim documentation and assisted with appeals preparation and claim corrections.
Customer Service Associate
2 Years 7 Months- Verified IPA delegation and DOFR guidelines to support accurate authorization processes.
- Processed prior authorizations, medical claims, and reimbursement requests while following ICD-10, CPT, and HCPCS coding standards.
- Resolved billing discrepancies by communicating with insurance carriers and provider offices regarding claim status.
- Educated patients on insurance coverage, deductibles, co-payments, and Explanation of Benefits (EOBs).
- Managed high volumes of billing inquiries and claim follow-ups while maintaining accurate documentation.
Education
Associate degree
Skills
Prior Authorization Processing
Medical Claims Processing
Denials & Appeals Research
Insurance Eligibility & Benefits
Medicare & Medicaid
Commercial Insurance
ICD-10 / CPT / HCPCS
EOB Analysis
Claim Follow-Up
Claim Corrections
Provider Relations
IPA Delegation & DOFR
HIPAA Compliance
Epic
APeX
CRM Systems
Healthcare Operations
Apex
Timeline
Prior Authorization Specialist
Evolent Health
03.2024 - 08.2026Read More
Intake/Referral Specialist
Acelis Connected Health
08.2023 - 03.2024Read More
Customer Service Associate
H&H Call Center
01.2021 - 08.2023Read More
University of Phoenix
Associate degree
Read More