Healthcare Virtual Assistant | Prior Authorization & Claims Specialist | Medical

Healthcare insurance professional with over six years of experience supporting major U.S. health insurance providers, Aetna and Highmark Health. Experienced in Prior Authorization, Behavioral Health, Provider Support, Quality Assurance, and Quality Management. Began my career as a Provider Support, assisting healthcare providers with benefits and eligibility verification, claims inquiries, prior authorization requests, and coverage-related concerns. Through consistent high performance and strong healthcare insurance expertise, I was promoted to Quality Compliance Analyst, where I conducted quality evaluations, compliance reviews, performance assessments, and coaching initiatives to ensure adherence to client and regulatory standards. Further advanced to Assistant Manager for Quality, leading a team of Quality Analysts and overseeing quality performance, compliance initiatives, and continuous improvement programs. Partnered closely with Operations and leadership teams to drive service excellence, improve key performance metrics, enhance customer and provider experiences, and support organizational objectives. My experience spans Prior Authorization, Behavioral Health, and Medical Insurance operations, providing a comprehensive understanding of healthcare payer processes and provider support functions.

Provided customer service and provider support for Medicare Part B Buy-and-Bill prior authorization requests. Assisted healthcare providers with the initiation and processing of authorization requests, ensuring accurate collection and documentation of clinical information, treatment history, and required supporting documents. Served as a primary point of contact for providers regarding coverage requirements, authorization status, and policy guidelines. Maintained compliance with healthcare regulations and internal procedures while delivering timely, accurate, and professional support to facilitate efficient case processing and positive provider experiences.

Experienced Assistant Manager for Quality for a pioneering Highmark Health insurance account, responsible for overseeing quality performance, compliance standards, and operational excellence. Led and supervised a team of Quality Analysts, ensuring the consistent achievement of key quality metrics, service-level expectations, and client requirements. Collaborated closely with Operations leadership to identify performance gaps, implement process improvements, and develop action plans that enhanced service quality, productivity, and customer experience. Conducted quality reviews, calibration sessions, coaching initiatives, and root-cause analyses to drive continuous improvement and support business objectives.