PharmD-Trained Remote Prior Authorization Specialist for US Specialty Pharmacy (6+ Years)

Client overview: A US-based multi-specialty physician group (8-physician practice, 1,500 PA cases per month). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Supported the team in handling the assigned scope of remote prior authorization specialist work, supporting team to achieve targets.

• Supported the team in handling day-to-day operations for the client, where the team would obtain prior authorizations for medications, imaging, and procedures, supporting team to achieve targets.
• Pulled clinical documentation including chart notes, lab values, imaging reports, prior failed therapies and step therapy history to support medical necessity per InterQual and MCG criteria.
• Did daily follow-up with payers on pending PA requests, capturing reference numbers, expected turnaround times, and approval or denial outcomes inside the EHR PA log.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, prepping the clinical packet and scheduling on the calendar.
• Filed appeals with supporting documentation for denied PAs, following payer-specific appeal timeline (usually 60 to 180 days), with focus on overturn rate.
• Helped the team follow up with insurance companies on pending authorization requests, with weekly review by US client supervisor on quality and turnaround.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 98% and above on the last review window.
• Worked with Staffingly's HIPAA-compliant AI assistant and Gemini, ChatGPT, and Claude for payer policy lookup, denial pattern matching, and first-pass appeal letter drafting on de-identified case notes; attended Staffingly's AI for Healthcare Operations bootcamp covering safe LLM use boundaries.
• Additional scope from the resume of record: I was the 1st employee in this role, which is a PSA position. My.
• Trained on Staffingly's custom PA AI app for clinical-criteria matching and HIPAA-safe ChatGPT for medical-necessity drafts on de-identified data. Completed AI in Prior Authorization bootcamp.
• Trained on Staffingly's custom AI app for clinical-criteria matching and a HIPAA-safe ChatGPT setup for medical-necessity letter drafting on de-identified data. Finished AI in Prior Authorization bootcamp.

Client overview: A US-based multi-specialty physician group (12-provider clinic, 2,000+ authorizations monthly). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Supported the team in handling the assigned scope of remote prior authorization specialist work, supporting team to achieve targets.

• Supported the team in handling day-to-day operations for the client, where the team would submit prior authorization requests via payer portals and fax, supporting team to achieve targets.
• Submitted prior authorization requests through Availity, CoverMyMeds ePA, Surescripts, and payer-specific portals (Aetna, BCBS, UHC, Cigna, Humana, Medicare Advantage), plus fax submissions for older payers.
• Pulled clinical documentation including chart notes, lab values, imaging reports, prior failed therapies and step therapy history to support medical necessity per InterQual and MCG criteria.
• Did daily follow-up with payers on pending PA requests, capturing reference numbers, expected turnaround times, and approval or denial outcomes inside the EHR PA log.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, prepping the clinical packet and scheduling on the calendar.
• Helped the team obtain prior authorizations for medications, imaging, and procedures, with weekly review by US client supervisor on quality and turnaround.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 98% and above on the last review window.

Client overview: A US-based multi-specialty physician group (5-clinic group, 800+ PA submissions weekly). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Supported the team in handling the assigned scope of remote prior authorization specialist work, supporting team to achieve targets.

• Supported the team in handling day-to-day operations for the client, where the team would follow up with insurance companies on pending authorization requests, supporting team to achieve targets.
• Did daily follow-up with payers on pending PA requests, capturing reference numbers, expected turnaround times, and approval or denial outcomes inside the EHR PA log.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, prepping the clinical packet and scheduling on the calendar.
• Filed appeals with supporting documentation for denied PAs, following payer-specific appeal timeline (usually 60 to 180 days), with focus on overturn rate.
• Communicated PA status to clinical staff and patients including out-of-pocket cost expectations under formulary tier and benefit design.
• Helped the team verify insurance benefits and confirm coverage prior to service, with weekly review by US client supervisor on quality and turnaround.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 98% and above on the last review window.

Client overview: A US-based multi-specialty physician group (specialty practice with 600+ PA cases per month). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Supported the team in handling the assigned scope of remote prior authorization specialist work, supporting team to achieve targets.

• Supported the team in handling day-to-day operations for the client, where the team would follow up with insurance companies on pending authorization requests, supporting team to achieve targets.
• Did daily follow-up with payers on pending PA requests, capturing reference numbers, expected turnaround times, and approval or denial outcomes inside the EHR PA log.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, prepping the clinical packet and scheduling on the calendar.
• Filed appeals with supporting documentation for denied PAs, following payer-specific appeal timeline (usually 60 to 180 days), with focus on overturn rate.
• Communicated PA status to clinical staff and patients including out-of-pocket cost expectations under formulary tier and benefit design.
• Helped the team verify insurance benefits and confirm coverage prior to service, with weekly review by US client supervisor on quality and turnaround.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 98% and above on the last review window.