Healthcare Operations | Referral Intake, PA Insurance Verification
Bataan
Hi, I’m Maureen and I have over 8 years of experience working remotely in the BPO and U.S. healthcare industry, with a strong background in customer and technical support, as well as client and patient-facing healthcare operations. For more than 5 years, I’ve worked directly with different U.S.-based healthcare organizations, including home health and hospice agencies, behavioral health and ABA agencies, and diagnostic imaging facilities. Throughout my healthcare career, I’ve had the opportunity to communicate and coordinate with a wide range of healthcare professionals and stakeholders, including physicians, nurses, physical, occupational, and speech therapists, home health aides, social workers, hospital case managers, discharge planners, radiology technicians, behavioral technicians, and different levels of leadership within the agencies I have supported such as CEOs, vice presidents, directors, managers, and supervisors. I’m also very comfortable communicating directly with patients and their families, and with insurance representatives. I’ve worked in referral intake and patient care coordination, prior authorization, insurance verification, scheduling, provider enrollment, and medical records retrieval. During the first three years of my career, I worked in customer service and technical support roles. Over time, I was promoted into a Healthcare Operations Team Lead role. In my current position, I support employees handling different healthcare-related functions, while also serving as a subject matter expert, trainer, and quality analyst. I’ve also become comfortable working with different systems and technologies, including EMR and EHR systems, CRM platforms, payer portals, referral platforms, softphones, productivity monitoring tools, AI tools, Google Workspace, and Microsoft Office 365. I’m also experienced in managing different communication channels, including email, e-fax, chat, text messaging, and both inbound and outbound calls.
Cliniqon, full_time
Jul 2022 to Present
Lead and supervise a multidisciplinary remote healthcare team of 30+ professionals supporting U.S.-based healthcare organizations across referral intake, patient care coordination, utilization management, prior authorization, billing, credentialing, provider enrollment, recruitment, and administrative operations. Oversee attendance, productivity, quality, compliance, SLAs, and KPIs while serving as the primary liaison between internal teams and U.S. clients. Manage operational and employee escalations, coordinate cross-functional resolutions, provide leadership reporting and workforce updates, conduct risk assessments, and develop mitigation plans to support service delivery and client retention. Lead quality assurance, coaching, performance management, onboarding, cross-training, SOP development, and process improvement initiatives aligned with CMS, payer, HIPAA, and client requirements. Support workforce planning, recruitment, interviewing, resource allocation, incident management, and business continuity. Provide hands-on expertise in patient care coordination and referral intake for Home Health and Hospice agencies, managing referrals from initial intake through Start of Care (SOC), ongoing coordination, and pre-billing handoff. Evaluate clinical documentation, determine appropriate levels of care and skilled disciplines, verify insurance eligibility and benefits, coordinate with patients, physicians, hospitals, SNFs, ALFs, and clinicians, track Face-to-Face requirements, coordinate admissions, and perform chart quality reviews to ensure documentation completeness and billing readiness. Manage provider enrollment and credentialing activities by preparing initial and revalidation applications, validating provider information, submitting documentation through commercial payer portals, tracking applications, responding to payer requests, and resolving enrollment issues. Handle end-to-end prior authorization for MRI, CT scans, and behavioral health services, including insurance verification, medical necessity review, clinical documentation and ICD-10/CPT validation, authorization submissions, follow-ups, peer-to-peer coordination, denials, appeals, reconsiderations, and payer communication. Maintain accurate EMR records and develop SOPs, workflow guides, and training materials. Additionally, support healthcare business development through market research, lead generation, client outreach, discovery meetings, solution presentations, and prospective client onboarding.
LKN Global Services Inc. , full_time
Jan 2021 to Jan 2022
Managed the end-to-end patient care coordination and referral intake process for U.S.-based Home Health services, from initial referral through Start of Care (SOC), ongoing visit coordination, and pre-billing handoff. Evaluated inbound referrals and clinical documentation to determine appropriate skilled services, including SN, PT, OT, and ST. Managed complex prior authorization requests for MRI, CT scans, and behavioral health services by reviewing medical records, ICD-10 and CPT codes, and payer medical necessity criteria. Handled denial management, appeals, reconsiderations, and peer-to-peer reviews while following up with payers to secure timely determinations. Performed insurance eligibility and benefits verification, including Coordination of Benefits (COB), across Medicare, Medicaid, Managed Medicare, and Commercial plans. Utilized payer portals such as Availity, eviCore, Carelon, and Optum to submit, track, and resolve authorization requests, ensuring accurate documentation, regulatory compliance, and timely access to patient care.