Patricia Britton
Philadelphia
Summary
Detail-oriented healthcare professional with extensive experience in prior authorizations, insurance verification, and pharmacy reimbursement. Expertise in managing high-volume authorizations and claims workflows while ensuring compliance with payer and regulatory requirements. Proficient in coordinating with providers, insurance carriers, and patients to efficiently resolve complex issues and support timely access to care. Recognized for exceptional communication skills, accuracy, and a strong problem-solving mindset.
Overview
11
11
years of professional experience
Work History
Care Review Processor
Molina Healthcare Insurance
08.2024 - Current
- Managed prior authorization requests from physician offices, ensuring timely patient treatment and adherence to payer regulations.
- Conducted verification of insurance eligibility and patient demographics to facilitate seamless care coordination.
- Facilitated timely authorization for acute rehabilitation, inpatient medical services, outpatient surgical interventions, pharmacy needs, durable medical equipment, genetic testing, home health agency support, and behavioral health visits, enhancing patient care delivery.
- Reviewed and verified ICD-10 and CPT codes to ensure adherence to authorization requirements.
- Reviewed and assessed electronic medical records to validate eligibility benefits and provider contracting status for compliance.
- Engaged with physician offices to retrieve essential clinical documentation, ensuring adherence to departmental standards.
Prior Authorization Specialist (Temp)
Medix Staffing Company Temple University Hospital
02.2024 - 08.2024
- Conducted thorough evaluations of electronic medical records to process high-volume prior authorization requests, ensuring accurate eligibility and benefits verification.
- Ensured accuracy and compliance of authorization submissions through meticulous verification of ICD-10 and CPT codes.
- Streamlined denial workflows by coordinating retroactive authorization requests and facilitating medical necessity appeals.
- Engaged with insurance carriers to gather additional documentation essential for processing approvals.
- Managed daily processing of 80+ authorizations to ensure timely access to outpatient oncology radiology services for Medicare A&B, Medicaid, and commercial plans.
- Maintained and organized epic patient records by integrating authorization numbers and clinical documentation for streamlined access.
- Facilitated authorization processes for Medicare A&B, Medicaid, and multiple commercial and federal insurance plans to ensure compliance and efficiency.
Pharmacy Reimbursement Specialist (Temp)
Iqvia All Care Plus Pharmacy
09.2023 - 02.2024
- Facilitated reimbursement processes by collecting and submitting documentation for Medicare Part D and commercial patients.
- Classified patients according to insurance type to facilitate efficient reimbursement processes.
- Coordinated patient participation in copay assistance and patient assistance programs to enhance affordability of healthcare services.
- Engaged with insurance carriers to ensure accurate resolution of billing discrepancies and payment challenges.
- Conducted thorough reviews of denied and rejected claims, submitting necessary corrections and appeals to facilitate reimbursement.
Insurances Verification Specialist
Penn Presbyterian Medical Center Hospital
09.2022 - 08.2023
- Secured outpatient prior authorizations for radiology and cardiology services.
- Assessed and confirmed eligibility and benefits to ensure compliance with Medicare A & B, Medicaid, and commercial insurance standards.
- Maintained Accurate and compliant patient authorization records within Epic
- Systematically documented provider and payer interactions in established formats to facilitate effective communication tracking.
- Inputted ICD-10 and CPT codes into Epic to maintain compliance with healthcare regulations.
- Identified relevant clinical documentation and facilitated authorization requests to ensure insurance approval.
Appeals Intake Coordinator
AmeriHealth Caritas Health Insurance
02.2020 - 08.2022
- Facilitated efficient processing of appeals and complaint requests for DM pharmacy LTSS, enhancing service delivery and client satisfaction.
- Facilitated timely review of appeals submitted via phone, fax, and email to enhance operational efficiency.
- Drafted and issued acknowledgment letters to enhance communication with members and providers.
- Conducted thorough verification of member eligibility and benefits to support effective appeal processes.
- Delivered clear and professional communication of approval and denial decisions to maintain stakeholder trust.
- Developed comprehensive appeals ensuring consent compliance, facilitating thorough review by medical providers.
Call Center Customer Service Representative
AmeriHealth Caritas Health Insurance
11.2019 - 02.2020
- Processed and responded to inbound calls across multiple business sectors, ensuring prompt and efficient service in a dynamic call center setting.
- Addressed member inquiries regarding prescription medical benefits billing to enhance service satisfaction.
- Validated member eligibility for correspondence and internal referral processes.
- Reviewed incoming correspondence and internal referrals to determine member plan eligibility accurately.
Direct Support Professional
Resources Human Development
11.2014 - 01.2020
- Provide daily support to residents who are diagnosed with mental illness and substance abuse
- Supports the development of a participant’s recovery plan, maintained medication stock, administered medications
- Report and discuss observations with case manager
- Supports participants in the self-management of critical or crisis situations
- Build and gain relationships to ensure patient safety and improve outcomes
- Telephone answering, filing, ordering supplies for the unit, copying, faxing paperwork to other RHD programs
Education
Diploma -
Simon Gratz High School
Philadelphia, PA06.2010
Skills
- Insurance authorization management
- Reimbursement process management
- ICD-10 & CPT Coding Review
- Claims processing and resolution
- Patient & Provider Communication
Timeline
Care Review Processor
Molina Healthcare Insurance
08.2024 - Current
Prior Authorization Specialist (Temp)
Medix Staffing Company Temple University Hospital
02.2024 - 08.2024
Pharmacy Reimbursement Specialist (Temp)
Iqvia All Care Plus Pharmacy
09.2023 - 02.2024
Insurances Verification Specialist
Penn Presbyterian Medical Center Hospital
09.2022 - 08.2023
Appeals Intake Coordinator
AmeriHealth Caritas Health Insurance
02.2020 - 08.2022
Call Center Customer Service Representative
AmeriHealth Caritas Health Insurance
11.2019 - 02.2020
Direct Support Professional
Resources Human Development
11.2014 - 01.2020
Diploma -
Simon Gratz High School