Fernando - Authorization RCM Specialist

Demonstrated experience with EPIC.

Demonstrated experience with EIQ.

Demonstrated experience with Payer Portals.

Demonstrated experience with Athena.

Demonstrated experience with Claims/Denials Management.

Recognized as Top Performer for Productivity in May 2026, exceeding department case-resolution targets.. Achieved the lowest rate of returned/rejected cases in the department, reflecting high accuracy in claims review and documentation.. Reviewed and processed denied claims, verifying eligibility and coding accuracy to determine appropriate next steps.. Prepared and submitted appeals and reconsiderations to insurance companies to secure timely reimbursement.. Analyzed clinical documentation, denial letters, and CPT codes within the revenue billing cycle to support accurate resolution of denials.. Coordinated with insurance payers via mail and fax communications to resolve outstanding authorization issues.

Managed scheduling, cancellations, and rescheduling of appointments for Universal Specialties and Pediatrics departments.. Coordinated lab appointments strictly for approved tests, including bloodwork and seasonal vaccines.. Processed pediatric documentation requests, including school forms, vaccine records, and medical records.. Handled prescription refill requests and coordinated internal/external specialty referrals.. Supported the HOMA department during the final four months of the assignment.

Resolved service requests for members enrolled in Dual Special Needs Plans (DSNP), including seniors (65+), individuals with disabilities, and low-income members with Medicare/Medicaid coverage.. Coordinated transportation to medical appointments and processed pharmacy refills and prescription reimbursements.. Identified in-network providers according to each member's specific plan and confirmed OTC card monthly benefit amounts.. Applied empathetic, needs-based problem solving to address sensitive member circumstances.

Performed device unlocking, firmware flashing, and factory resets across multiple platforms.. Diagnosed and resolved operating system issues on iOS, Android, and Windows devices.

Identified customer needs and recommended footwear brands based on opportunity cost and value.. Applied negotiation techniques to close sales and improve customer satisfaction.. Analyzed inventory data to identify best-selling models and inform seasonal sales campaigns.

Managed administrative staff and implemented operational policies and procedures.. Coordinated daily office operations, including scheduling, budgeting, and recordkeeping.. Increased revenue through process improvements and optimized scheduling with dental professionals.

Processed cell phone and tablet purchase cases through internal systems, verifying customer identity and payment validity with banks (fraud and security review).. Managed order approval, programming, and shipment upon successful verification.. Supported small business associations with administrative processes to improve sales and financial practices.