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Prior authorization specialist skills for your resume and career

Updated January 8, 2025
5 min read
Below we've compiled a list of the most critical prior authorization specialist skills. We ranked the top skills for prior authorization specialists based on the percentage of resumes they appeared on. For example, 17.7% of prior authorization specialist resumes contained patients as a skill. Continue reading to find out what skills a prior authorization specialist needs to be successful in the workplace.

15 prior authorization specialist skills for your resume and career

1. Patients

Here's how prior authorization specialists use patients:
  • Adjudicated and resolved insurance issues for patients on kidney dialysis; communicated with other medical professionals to obtain approval for expensive medications
  • Managed quality communication, patient support and service representation with patients and providers to establish equipment/procedures statuses and expedited orders.

2. Customer Service

Customer service is the process of offering assistance to all the current and potential customers -- answering questions, fixing problems, and providing excellent service. The main goal of customer service is to build a strong relationship with the customers so that they keep coming back for more business.

Here's how prior authorization specialists use customer service:
  • Maintained excellent customer service for all in-bound calls from medical providers and pharmacies requesting prior authorizations for prescription medications.
  • Provided superior customer service through phone/fax management skills, computer documentation of codes and clinical information for claims.

3. Medical Necessity

Here's how prior authorization specialists use medical necessity:
  • Determined medical necessity of inpatient hospitalization.
  • Analyzed and evaluated medical records (and all available health data) to make medical necessity determinations within required turn-around times.

4. Medical Terminology

Here's how prior authorization specialists use medical terminology:
  • Acquired knowledge of medical terminology and procedures relating to pain management.
  • Gained extensive knowledge of medical terminology and health insurance programs.

5. Clinical Resource

Here's how prior authorization specialists use clinical resource:
  • Provide clinical knowledge and act as a clinical resource to non clinical team.
  • Acted as clinical resource to referral staff and made appropriate referrals.

6. Authorization Process

An authorization process is a server security mechanism process to determine whether or not a user has access to use a resource -- files, computer programs, application features, data, etc. The aim is to control the access and the processing that follows solely depend on the function that triggered the authorization requirements.

Here's how prior authorization specialists use authorization process:
  • Presented training sessions to internal departments and providers regarding prior authorization process, coverage criteria, and appropriate coding for reimbursement
  • Ensured Prior Authorization process was fully completed without influencing authorized on how to specifically answer Prior Authorizations questions/criteria.

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7. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how prior authorization specialists use data entry:
  • Maintain accurate and timely data entry of prior-authorization requests within the systems.
  • Conduct intake/data entry for prior authorization request.

8. Utilization Management

Here's how prior authorization specialists use utilization management:
  • Communicate effectively and interact with the provider group and health plans regarding utilization management and referral authorization inquiries.
  • Developed and implemented Utilization Management/Disease Management referral program utilizing URAC/NCQA guidelines for all contracted entities.

9. CPT

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Here's how prior authorization specialists use cpt:
  • Confirm and correct ICD9 and CPT codes using EncoderPro and books, and conversations with providers, and Access Data Base.
  • Abstracted information from medical charts and surgical notes to assign CPT and ICD 9 for billing.

10. Authorization Request

Here's how prior authorization specialists use authorization request:
  • Reviewed physician-submitted prior authorization requests for approval, consistently achieving the fastest turnaround times and highest quality scores in the department.
  • Identify authorization requests with insufficient supportive documentation and contact referring provider for necessary documentation for a determination to be rendered.

11. Medicaid

Here's how prior authorization specialists use medicaid:
  • Worked with insurance companies regarding benefit information - including Medicare and Medicaid.
  • Reviewed and verified documentation for Medicaid Therapy in Case Tracker software application.

12. Appeals

Here's how prior authorization specialists use appeals:
  • Review authorization from payer to determine approved/denied items and submit appeals if allowed.
  • Coordinated with providers for further authorization, denial, appeals process information.

13. Patient Care

Patient care entails the diagnosis, recovery, and control of sickness as well as the maintenance of physical and emotional well-being through the use of healthcare providers' services. Patient care is described as services provided to patients by health practitioners or non-professionals under guidance.

Here's how prior authorization specialists use patient care:
  • Coordinate patient care utilizing policies and procedure.
  • Facilitate appropriate patient care to include but not limited to assessment of the patient's medical and physical needs.

14. Outbound Calls

An outbound call is made by the call center representative to the customers on behalf of the company. Such calls help increase sales and generate revenue for the organization.

Here's how prior authorization specialists use outbound calls:
  • Placed outbound calls to necessary parties to obtain information and updates to a PA status if necessary or requested.
  • Send reviews to medical directors and make outbound calls to UM pharmacist for urgent decisions regarding medical request.

15. Phone Calls

Phone calls are a wireless or wired connection made over a telephone or a mobile phone between two people. Two parties are involved in a phone call, the caller and the receiver. A caller dials the number of the one he wants to call, and the recipient hears a bell or a tune to which he picks up the call. The call establishes a connection between them through which they can communicate. The voice is converted into signals and is transmitted through wired or wireless technology.

Here's how prior authorization specialists use phone calls:
  • Handle telephone calls timely and accurately.
  • Utilize various means of communication, such as fax and phone calls, for exchange of information within many complex organizations.
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List of prior authorization specialist skills to add to your resume

The most important skills for a prior authorization specialist resume and required skills for a prior authorization specialist to have include:

  • Patients
  • Customer Service
  • Medical Necessity
  • Medical Terminology
  • Clinical Resource
  • Authorization Process
  • Data Entry
  • Utilization Management
  • CPT
  • Authorization Request
  • Medicaid
  • Appeals
  • Patient Care
  • Outbound Calls
  • Phone Calls
  • Home Health
  • HIPAA
  • Insurance Verification
  • Inbound Calls
  • EMR
  • CMS
  • ICD-10
  • Medical Services
  • Insurance Coverage
  • Insurance Carriers
  • InterQual
  • Clinical Criteria
  • Hippa
  • Insurance Benefits
  • Chemotherapy
  • Authorization Forms
  • Durable Medical Equipment
  • ICD-9
  • Pharmacy Benefits
  • Patient Confidentiality
  • Health Plan
  • Clinical Data
  • PBM
  • RX
  • Computer System
  • MRI
  • Denial Letters
  • Surgical Procedures
  • Medical Procedures
  • Clinical Review
  • Computer Database
  • HMO
  • Procedure Codes

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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