Prior Authorization Representative Resume Samples

The main job duty of a Prior Authorization Representative is to interact with customers and handle the complaints, and issues of customers relating to authorization processes. Typical work activities seen on the Prior Authorization Representative Resume include the following – listening to the concerns and questions of customers; providing answering or responses; providing information about products and services; taking orders, calculating charges and processing billing or payments; reviewing and making changes to customer’s accounts; and recoding details of customer’s contacts.

The most sought-after skills for the post include the following – strong writing skills, the ability to handle all types of complaints and issues; the ability to create a positive interaction with customers; patience; and strong problem-solving skills. While a degree is not mandatory, possessing a high school diploma and relevant training in the field is essential.

Prior Authorization Representative Resume example

Prior Authorization Representative Resume

Summary : Review case and insurance coverage information to customize the content of the call to the insurance company or physicians office.

Skills : Order Picker Experience, Reach Truck, Pallet Jack, Dock Stocker, Clamp Truck, Experience As Well.

Description :

    1. Answered calls from physician offices, hospitals, and patients using exemplary customer service skills.
    2. Accurately enter required information (non-clinical and structured clinical data) into computer database.
    3. Reviewed structured clinical data matching it against specified medical terms and diagnoses or procedure codes (without the need for interpretation) and follow established procedures for authorizing request or referring request for further review.
    4. Refered callers to benefit departments of correct claims administrator when requesting benefit information.
    5. Maintained patient confidentiality as defined by state, federal and company regulations.
    6. Established effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
    7. Actively supported departmental and corporate strategic plans and ensure successful implementation.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Bachelor's In Psychology


Sr. Prior Authorization Representative Resume

Summary : Dedicated Customer Service Representative motivated to maintain customer satisfaction and contribute to company success. Customer Service Representative who maintains a high level of professionalism, patience and efficiency to minimize customer dissatisfaction and increase customer loyalty.

Skills : Customer Service, Computer, Problem Solving, Office, Data Entry, Working With People With Disabilities.

Description :

    1. Dedicated team of Excellence Team Scan Medicare.
    2. Dedicated team of Excellence Team United American Medicare.
    3. Cross-trained to handle all Wellpoint and Commercial Medicare accounts.
    4. Provided floor support when Supervisor and Resolution Specialist are unavailable.
    5. Initiated and or/completed Prior Authorization request for Doctor Offices, Pharmacies, Patients and Clients via phone or fax.
    6. Worked with pharmacist to make correct determination on authorization request.
    7. Assisted physicians and pharmacist in completing coverage documentations.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Senior
Education
Education
Associate Of Science


Jr. Prior Authorization Representative Resume

Headline : Customer Service Representative who maintains a high level of professionalism, patience and efficiency to minimize customer dissatisfaction and increase customer loyalty. Core Qualifications High customer service standards.

Skills : inventory management (8 years), quality control (8).

Description :

    1. Assisted with the orientation of providers to the Plan's authorization and review procedures and work closely with participating physicians to secure .
    2. Gaven explanations as to why a specific drug was not covered by the patient's insurance coverage.
    3. Responsible for process prior authorization's for high end prescriptions.
    4. Verified the status of an current pending authorization.
    5. Facilitated resolution of drug coverage issues and pro-actively address, research.
    6. Resolved issues while maintaining accurate and complete.
    7. Consulted doctors and pharmacists to confirm various medical information.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Junior
Education
Education
General Studies

Prior Authorization Representative III Resume

Summary : To obtain a position that commensurate with professional experience and educational background.

Skills : Microsoft Office, Medlook, Medical Billing And Coding.

Description :

    1. Handled incoming calls from clients to enable members to maximize their prescription benefit program.
    2. Entered requests from clients via e-mail, fax, or postal mail.
    3. Documented and tracked requests and contacts clients for clarifications of requests.
    4. Documented client contacts using department data base.
    5. Managed file transfers from e-mail to Anchor.
    6. Responded to complex or critical client issues.
    7. Maintained accurate and complete documentation of all contacts.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Master In Management

Prior Authorization Representative II Resume

Summary : Qualified Call Center Representative with nine years experience in fast-paced customer service call center environment. Personable and professional under pressure. Patient and empathetic customer service representative with extensive background in conflict resolution and customer care.

Skills : Microsoft Word, Excel and PowerPoint and Types 45 WPM.

Description :

    1. Experienced Prior authorization representative for nine years in a high volume call center taking up to 80 calls per day.
    2. Took inbound and outbound calls from physicians, physician office staff, patients and other health care providers.
    3. Reviewed clinical criteria by phone with health care professionals for authorization of medications from insurance plans.
    4. Politely explained authorization process in full detail to patients.
    5. Investigated and resolved patient inquires and complaints in a timely and empathetic manner.
    6. Carefully reviewed clinical criteria via phone with health care providers.
    7. Processed clinical criteria via fax to determine prescription coverage.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
High School Diploma

Prior Authorization Representative I Resume

Headline : A Pharmacy Technician looking to become part of a challenging environment where can expand skill set & knowledge. have been acknowledged for strong verbal communication and leadership skills and look forward to bringing these competencies to employer.

Skills : Excel, Editing And Proofreading, Microsoft Office, Organizational, Punctual, Reliable, Time Management, Sap.

Description :

    1. Reviewed and approved physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
    2. Supported Fraud and Abuse program system oversight by reviewing medication utilization records.
    3. Communicated any suspected fraud discovered.
    4. Recommended course of action for providers where patterns appears outside of guidelines and generally accepted pharmacy standards.
    5. Kept abreast of industry trends and regulatory changes in the pharmacy industry and incorporates knowledge in the performance of job duties.
    6. Identified problems in process/procedures or services and makes recommendations for improvements.
    7. Maintained a balance of productivity, quality and timeliness of job accountabilities.
    8. Participated in department self-audit procedures for on-going evaluation of service.
    9. Maintained and updated internal databases.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
Pharmacy Technician Program

Assistant Prior Authorization Representative Resume

Objective : Experienced professional seeking a challenging position in a people-oriented organization where can maximize 15 years of background experience in the Customer Service Industry to achieve the corporate goals of customer satisfaction. Core competencies include Attention to detail.

Skills : Data Entry, Filing Microsoft Word, Excel, Power Point, And Out Look. Xerox PDF, Editing, Quality Assurance. Critical Thinking, Complex Problem Solving, Time Management.

Description :

    1. Handled inbound/outbound calls from physicians, physician office staff, patients & other health care providers.
    2. Determined how to triage or respond to questions.
    3. Used good judgement in referring calls of a clinical nature to a Pharmacist as defined by protocol.
    4. Handled calls from patients concerning Managed Care Formulary customer service issues.
    5. Complied with all Manage Care SOP's as defined.
    6. Assisted Physicians, pharmacist, and members in understanding Utilization Management and or formulary coverage rules, in determining whether to initiate a formal request for coverage or not.
    7. Translated formal request for coverage into electronic cases in MHS's Coverage Determination Platform.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Executive
Education
Education
General Studies

Associate Prior Authorization Representative Resume

Headline : Verifying or re-verifying insurance eligibility. Obtaining prior authorization and additional information required by the payor for billing.

Skills : Microsoft Office Suite, Data Entry, Customer Service, Employee Relations, Hipaa, Leadership.

Description :

    1. Required information (non-clinical and structured clinical data) into computer database.
    2. Reviewed structure clinical data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for authorizing request or referring request for further review.
    3. Attached incoming information to ICare database and follow established procedures for distributing information for further review.
    4. Called back providers with precertification numbers as needed and file completed precertification requests as per established procedures.
    5. Called hospitals for discharge dates as needed.
    6. Refered callers to benefit departments of correct claims administrator when requesting benefit information.
    7. Maintained patient confidentiality as defined by state, federal and company regulations.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
Diploma

Prior Authorization Representative/Director Resume

Summary : Facilitated drug coverage decision by applying information received from healthcare professionals to client condition of coverage.

Skills : Microsoft Office, Drug screening, Insurance Verification, Problem Solving, Team Leadership, Inventory Management, Professionalism.

Description :

    1. Worked in a call center in the Clinical Triage Unit/Prior Authorization department.
    2. Answered patient/provider calls on a wide range of topics.
    3. Asked the right questions to get the information needed to make accurate assessments.
    4. Used computer to access member medical records and make coverage determinations.
    5. Educated and given the caller advice on handling their situation.
    6. Routed calls to appropriate resource.
    7. Documented all call information according to standard operating procedures, complete call logs and document in appropriate applications.
    8. Addressed customer service inquiries in a timely and accurate fashion.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Bachelors Of Science

Prior Authorization Representative Resume

Summary : Seeking a challenging career which will utilize skills and abilities in customer service, Accomplishments: Received awards of Recognition Received bonuses every month , by meeting quotas and providing quality customer care to patients, physicians, pharmacist and health care professionals.

Skills : Office, Excel, Word, Yardi, Internet.

Description :

    1. Able to work in a team environment and contribute Accomplished and energetic to maintain a positive, open and objective attitude towards others; as well as commitment to the job task,with accuracy and efficiency.
    2. Wrote and Created between 85 - 100 Medical Cases for Prior Authorizations and transformed to letters in which process from Approvals, Extension, and .
    3. Provided insurance company representatives with an overview of the services in which coverage is being requested in the attempt to obtain prior authorization.
    4. Answered questions regarding the reimbursement process and direct testing specific and treatment questions.
    5. Completed SMN (statement of medical necessity) form based on client or insurance requirements and fax to the ordering physician’s office for completion.
    6. Initiated outbound call to doctors office and patients to obtain clinical information.
    7. Completed appeal criteria, advise of appeal processes and notified appropriate individuals of coverage determinations.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Medical Assistant