Nerio Jr P.

Prior Authorization Specialist 1.) check patient's benefit and eligibility these includes amount to pay, Referral validity dates, checking in the system and portals 2.) Submit initial prior authorization requests for IOP and PHP admissions across PSCS Medicaid, BCBS, UHC/Optum, Aetna, and Cigna/Evernorth in a timely manner 3.) Track authorization status and our internal authorization log; flag gaps and expiring auths proactively 4.) Coordinate peer-to-peer calls between our Clinical Director and payer Medical Directors when initial requests are denied 5) Prepare and submit Level I and Level II appeals with supporting clinical documentation; maintain denial reason tracking 6.) Liaise with Jane EMR to ensure documentation supports authorization requests (treatment plans, group notes, assessments) 7.) Communicate authorization updates to the clinical team and update Jane EMR accordingly 8.) Maintain compliance with all HIPAA privacy and security standards in every communication and workflow 9.) Conduct concurrent review submissions at required intervals; document clinical justification aligned to medical necessity criteria and payer-specific guidelines 10.) process incoming referrals and enrolling in the system, update the patient information accordingly 11.) payment and denial posting Proven experience working in an EMR system like DR Chrono and Jane System. Knowledgeable for the following different Insurance: Commercial payers: BCBS & Anthem, Aetna, UHC, Cigna, TriWest & VA Community, MODA, Providence Medicare & Managed Medicaid • Bachelor's degree in Electronics and Communication Engineering • Proven experience in maintenance management, preferably in a manufacturing or industrial setting. • Strong technical knowledge and understanding of mechanical, electrical, and hydraulic systems, as well as equipment maintenance and repair techniques. • Excellent leadership and team management skills, with the ability to motivate and inspire a team to achieve performance targets. • Effective problem-solving and decision-making abilities, with a focus on finding innovative solutions to maintenance challenges. • Solid organizational and time management skills, with the ability to prioritize tasks, meet deadlines, and manage multiple projects simultaneously. • Strong communication and interpersonal skills, with the ability to collaborate effectively with individuals at all levels of the organization. • Proficiency in computerized maintenance management systems (CMMS) and other relevant software applications. • Knowledge of safety regulations and best practices in maintenance operations. • Flexibility to work evenings, weekends, or on-call as needed.