LOURDES N. CASILAO

Prior Authorization Specialist

Physical Therapy and Occupational Therapy

📋 Core Responsibilities

• Process Prior Authorizations: Review and submit prior authorization requests for Physical & Occupational Therapy procedures, and services to insurance companies.
• Verify Coverage: Confirm patient insurance benefits and eligibility before submitting requests.
• Communicate with Providers: Work closely with physicians, nurses, and other healthcare staff to gather necessary documentation.
• Coordinate with Insurers: Contact insurance companies to follow up on pending authorizations, clarify requirements, and resolve issues.
• Documentation Management: Maintain accurate records of authorization requests, approvals, denials, and appeals.
• Appeals Handling: Assist in preparing and submitting appeals for denied authorizations.
• Compliance: Ensure all requests meet HIPAA and insurance regulatory requirements.

🧩 Skills & Competencies

• Strong knowledge of medical terminology, insurance processes, and healthcare regulations.
• Excellent communication skills for interacting with providers, insurers, and patients.
• Attention to detail and organizational skills for managing multiple requests simultaneously.
• Ability to work with PTEVERYWHERE and insurance portals.
• Problem-solving skills to address denials and delays effectively.

🎯 Goals of the Role

• Reduce delays in patient care by securing timely authorizations.
• Minimize claim denials and financial losses for the healthcare organization.
• Support providers and patients by ensuring smooth access to necessary treatments.

• Billing (RCM)
• Account handle
• Breaking Silos in Medicine LLAC
• WC health/Alliance mental health
• First Person Care Clinic
• Duties & Responsibility
• Verify Insurance Coverage: Initiate communication with insurance companies to verify patients' insurance coverage details and confirm eligibility
• Document Management: Accurately document and update patient insurance information through the company's systems
• Customer Support: Provide support to patients and healthcare providers, addressing eligibility and benefits inquiries.
• Communication with Providers: Liaise with healthcare providers to confirm service coverage and benefit details.
• Maintain Records: Keep detailed records of benefits and eligibility decisions, ensuring all information is updated and easily accessibly
• Billing - Inbound/outbound Calls for collecting copay
• Schedule appointment and cancel appointment per provider

• Account -health insurance BCBS North Carolina
• Duties & Responsibility
• Handling billing eligibility benefits, claims, technical support.
• Pharmacy and checking authorizations
• Inbound calls
• Payment collections
• Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
• Exceeded performance metrics consistently, earning recognition as a top performer within the team.
• Resolved escalated customer issues, restoring confidence in company's commitment to service excellence.
• Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.

• Duties & Responsibility
• Timekeeping
• Documentation & Paper Works
• Monitoring of Employee (Roving & Employee Concern)
• Billing & Memorandum
• Orienting new employees to the organization (Setting up a designated log in & Work station etc.
• Processing Payroll
• Scheduling Job Interview and assisting in interview process
• Know how to Operate MS WORD/ MS EXCEL, MS POWER POINT.
• Prepare monthly and yearly evaluation of employee
• Report man power to client and attend meeting
• Assisted in payroll processing, ensuring accurate compensation for all employees based on hours worked and applicable deductions.
• Maintained human resources information system and kept employee files up to date and accurate.
• Handled employee inquiries and complaints regarding policy and benefits issues.
• Worked with managers to achieve compliance with organizational policies, providing clarifying information and recommending necessary changes.

• Duties & Responsibility
• Monitoring Machine documentation
• Standard Procedure Check sheet & Documentation
• Schedule of Employee (Weekly Attendance)
• Encoding Finished Good & Stocks
• Managed documents by organizing forms, making photocopies, filing records, preparing correspondence, and creating reports.
• Maintained daily production logs of activities and completed work.
• Completed daily data back-up to secure records.