Remote Prior Authorization Specialist for Specialty Pharmacy and Specialty Drug PA

Client overview: A US-based multi-specialty physician group (8-physician practice, 30-40 PA cases per day). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Kindly handled the assigned scope of remote prior authorization specialist work, kindly making sure the client is satisfied with the work.

• Kindly handled day-to-day operations for the client, where the team would submit prior authorization requests via payer portals and fax, kindly making sure the client is satisfied with the work.
• Submitted prior authorization requests via payer portal (Availity, Aetna, BCBS, UHC, Cigna, Humana), CoverMyMeds ePA, and fax for medications, imaging (MRI, CT, PET), and procedures.
• Worked with Staffingly's internal AI assistant for InterQual and MCG criteria summarization on de-identified PA samples, plus HIPAA-aware Gemini for appeal letter editing; completed the AI for Healthcare PA bootcamp.
• Pulled clinical documentation (chart notes, lab values, imaging reports, prior trial data) to support medical necessity per payer criteria like InterQual and MCG.
• Did daily follow-up calls with payers until approval or denial was received, with reference numbers and turnaround times documented in the EHR.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, scheduling on the calendar and prepping the clinical packet.
• Also helped the team obtain prior authorizations for medications, imaging, and procedures, which the supervisor and the US client would review on weekly call.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 95% and above on the last review window, kindly appreciated by the client.
• Additional scope from the resume of record: ⮚ Pharmacy Intern - Columbia Asia Hospital.
• Used Gemini and Claude inside Staffingly's HIPAA-secure tooling for denial reason classification and step-therapy templates. Joined internal AI for Auth Specialists bootcamp.
• Worked with Gemini and Claude inside Staffingly's HIPAA-secure tooling for denial reason classification and appeal templates. Completed internal AI for Authorization Specialists bootcamp.
• Worked with Staffingly's custom AI automation app for payer-policy lookup and denial-pattern matching. Used HIPAA-aware ChatGPT for first-pass appeal letter drafts on de-identified case notes. Completed AI for Prior Auth bootcamp.

Client overview: A US-based multi-specialty physician group (12-provider clinic with infusion suite, 50+ PA cases daily). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Kindly handled the assigned scope of remote prior authorization specialist work, kindly making sure the client is satisfied with the work.

• Kindly handled day-to-day operations for the client, where the team would verify insurance benefits and confirm coverage prior to service, kindly making sure the client is satisfied with the work.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, scheduling on the calendar and prepping the clinical packet.
• Filed appeals with supporting documentation for denied PAs, following payer-specific appeal timelines (usually 60 to 180 days).
• Communicated PA status to clinical staff and patients including out-of-pocket cost expectations under formulary tier and benefit design.
• Worked on step therapy exception requests and formulary tier exceptions, doing the documentation pulls for prior trial drugs.
• Also helped the team document all PA activity in the EHR with reference numbers and approval dates, which the supervisor and the US client would review on weekly call.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 95% and above on the last review window, kindly appreciated by the client.
• Additional scope from the resume of record: Position: Pharmaceutical Customer Service Executive (Promoted to Floor Supporter).

Client overview: A US-based multi-specialty physician group (15-provider multi-specialty group, 60-80 PA per day). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Kindly handled the assigned scope of remote prior authorization specialist work, kindly making sure the client is satisfied with the work.

• Kindly handled day-to-day operations for the client, where the team would document all PA activity in the EHR with reference numbers and approval dates, kindly making sure the client is satisfied with the work.
• Filed appeals with supporting documentation for denied PAs, following payer-specific appeal timelines (usually 60 to 180 days).
• Communicated PA status to clinical staff and patients including out-of-pocket cost expectations under formulary tier and benefit design.
• Worked on step therapy exception requests and formulary tier exceptions, doing the documentation pulls for prior trial drugs.
• Handled specialty drug PA including Humira, Stelara, Enbrel, Remicade, Rituxan, Keytruda, Opdivo with NDC and J-code accuracy.
• Also helped the team submit clinical documentation supporting medical necessity, which the supervisor and the US client would review on weekly call.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 95% and above on the last review window, kindly appreciated by the client.

Client overview: A US-based multi-specialty physician group (specialty practice with 6 providers, 25-35 PA daily). The work covered remote prior authorization specialist responsibilities for the client team, with payer mix across commercial and government plans.

Role summary: Kindly handled the assigned scope of remote prior authorization specialist work, kindly making sure the client is satisfied with the work.

• Kindly handled day-to-day operations for the client, where the team would submit prior authorization requests via payer portals and fax, kindly making sure the client is satisfied with the work.
• Submitted prior authorization requests via payer portal (Availity, Aetna, BCBS, UHC, Cigna, Humana), CoverMyMeds ePA, and fax for medications, imaging (MRI, CT, PET), and procedures.
• Pulled clinical documentation (chart notes, lab values, imaging reports, prior trial data) to support medical necessity per payer criteria like InterQual and MCG.
• Did daily follow-up calls with payers until approval or denial was received, with reference numbers and turnaround times documented in the EHR.
• Coordinated peer-to-peer calls between provider and payer medical director when initial PA was denied, scheduling on the calendar and prepping the clinical packet.
• Also helped the team obtain prior authorizations for medications, imaging, and procedures, which the supervisor and the US client would review on weekly call.
• Made sure HIPAA, payer-specific guideline, and internal SOP was followed on every transaction. Quality audit score was held at 95% and above on the last review window, kindly appreciated by the client.