prior authorization specialist resume example with 11+ years of experience

Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,
Professional Summary

Organized professional knowledgeable in working with many insurance payors including Medicaid, Medicare, and commercial plans. Confident prior authorization specialist with a background spent working in medical offices and with payors communicating effectively both orally and through writing. Most time spent in prior authorization was as a team lead so heavily experienced in proper training. Hardworking prior authorization specialist with successful background working closely with insurance company representatives to gain preapproval for procedures and testing as well as providing inpatient notifications. Detail-oriented performer with over 10 years of prior authorization knowledge from both a provider and a payor stand point. Considered a team player with exemplary multitasking skills and dependability.

  • Expert understanding of Medicare and Medicaid processes
  • Extensive expertise in obtaining as well as processing prior authorizations
  • Credentialing
  • Insurance verification and benefits
  • Effective communication skills
  • Medical terminology
  • EPIC
  • Excellent telephone etiquette
  • Self-motivated professional
  • Highly dependable and flexible
  • Multitasker
  • Team player
Work History
12/2020 to Current Prior Authorization Specialist Oregon Medical Group | Springfield, OR,

  • Reached out to insurance carriers to obtain prior authorization for testing and procedures.
  • Communicated with staff when additional information was required for authorization.
  • Verifying authorization requirements using various methods such as calling, utilizing web portals, and through fax.
  • Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.

06/2016 to 03/2021 Prior Authorization Specialist Lead Children's Hospital Of Wisconsin (CCHP) | City, STATE,
  • Training both staff and UM nurses on policy and procedures as well as creating and maintaining workflows.
  • Ensured timely and accurate processing of inpatient and outpatient notifications.
  • Verified eligibility, coordination of benefits, and covered vs non covered services.
  • Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
  • Efficiently performed insurance verification and pre-authorization functions.
  • Developed effective relationships with all other departments through clear communication.
  • Provided accurate and appropriate information in response to provider authorization inquiries.
  • Served as support for concurrent review nurses.
  • Performed sanctions checks on out of network providers through Streamline verify, OIG, NPDB, and licensing boards.
  • Initiated and negotiated single case agreements for out of network providers.
  • Participated in NCQA audit preparation.
03/2015 to 12/2020 Prior Authorization Specialist Lead Molina Healthcare | City, STATE,
  • In charge of training new staff members and being point of contact between medical directors, nurse reviewers, and specialists.
  • Effectively processed authorization requests in a timely manner.
  • Worked with both providers and members to verify eligibility, authorization status, and benefits.
  • Performed weekly checks of in network providers Wisconsin Medicaid certification.
  • Initiated single case agreements with out of network providers.
  • Audited work of the specialists to insure accuracy of the department.
  • Cleared claims workflow daily to ensure any held claims due to an authorization question were answered.
  • Processed both denial and approval letters for Medicaid and Marketplace members.
  • Set up peer to peer reviews between providers and our medical directors.
  • Reached out to insurance carriers to obtain prior authorization for testing and procedures.
  • Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
  • Verified eligibility and compliance with authorization requirements for service providers.
01/2012 to 03/2015 Prior Authorization Lead Wheaton Franciscan Healthcare | City, STATE,
  • Trained new staff on processes as well as provided ongoing resources for current staff.
  • Initiated authorization requests with payors for both inpatient and outpatient services.
  • Verified member eligibility and benefits.
  • Worked with doctor's and patients on any authorization concerns if authorizations were not in place within 24 hours of date of service.
  • Soley in charge for working J-code authorizations for our neurological department specializing in injectable drugs for patients with multiple sclerosis.
Expected in to to Bachelor of Science | Social Work Northern Arizona University, Flagstaff, AZ GPA:
Expected in 06/2011 to to Associate of Science | Criminology College of Lake County, Grayslake, IL GPA:
Expected in 06/2006 to to High School Diploma | Alexander Hamilton High School, Milwaukee, WI, GPA:

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Resume Overview

School Attended

  • Northern Arizona University
  • College of Lake County
  • Alexander Hamilton High School

Job Titles Held:

  • Prior Authorization Specialist
  • Prior Authorization Specialist Lead
  • Prior Authorization Specialist Lead
  • Prior Authorization Lead


  • Bachelor of Science
  • Associate of Science
  • High School Diploma

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