Healthcare Authorization Specialist with Open Availability
Resume:
Paulette Teh
Current Location: Lancaster, CA ****4
(Available within 24 – 48 Hours Prior Notice for interview and Immediately Available for start) Suppliers Summary:
● extensive years of healthcare member services and managed care experience, including strong background in prior authorization processing, insurance coverage verification, and benefits eligibility across Medicare, Medi-Cal, HMO, and PPO plans.
● has hands-on experience initiating and tracking prior authorizations, coordinating clinical documentation, communicating with physician offices and payers, and supporting appeals, retro authorizations, and complex authorization cases.
● Demonstrates working knowledge of ICD-9/ICD-10, CPT, HCPCS codes, evaluation & management documentation, medical billing review, and claims research, supporting reimbursement and authorization decisions.
● Experienced in working closely with Utilization Management teams, reviewing provider documentation, coordinating peer-to-peer reviews, and ensuring authorization requests meet payer guidelines and turnaround timelines.
● Strong patient access and provider coordination experience, supported by advanced Microsoft Excel, CRM systems, QNXT eligibility systems, and high-volume remote operations, with proven ability to manage multiple cases while maintaining accuracy, compliance, and customer service standards. Education:
Susan Miller Dorsey High School CA 1985
High School Diploma
United Education Institute, Encino CA 2020
Complete Certificate, MA UEI
Skills:
● Member services (60–80
calls daily)
● High-volume inbound call
handling
● Claims inquiry routing and
resolution
● Medicare, Medicaid,
Medi-Cal, HMO & PPO
eligibility verification
● Insurance benefits verification
● Prior authorization processing
● Authorization intake and
submission
● Authorization tracking and
follow-up
● Appeals and grievance
routing
● Utilization Management (UM)
coordination
● Peer-to-peer review
coordination
● Clinical documentation review
● Evaluation & Management
(E/M) level review
● Medical necessity
documentation support
● ICD-10-CM coding
verification
● CPT code verification
● HCPCS coding knowledge
● Modifier validation
● Medical billing review
● Re-billing and claim
corrections
● Auditing and compliance
review
● Collections support
● Research and claim
investigation
● Care coordination support
● Care management
collaboration
● New member enrollment
transition support
● Case management triage
● Provider services support
● Provider credential
verification
● In-network / out-of-network
verification
● Referral processing
● Community service referral
processing
● ECM authorization/referral
coordination
● Housing transition support
coordination
● Transportation coordination
for medical appointments
● HIPAA compliance
● Encrypted fax and secure
medical record handling
● Consent and Power of
Attorney processing
● Primary Care Physician
(PCP) change processing
● Healthcare ID generation and
distribution
● Invoice generation for
member responsibility
● Solar application eligibility
review (SCE role)
● Database monitoring and
documentation
● Authorization fax cover sheet
processing
● CRM case management
● Advanced Microsoft Excel
● Microsoft Word
● Microsoft PowerPoint
● SharePoint
● QNXT (Eligibility,
Demographics, Line of
Business)
● ABS state healthcare data
systems
● Triple G system
● GBS system
● UMK (Utilization
Management system)
● 24-hour billing cycle
processing
● New hire training support
(member
services/commercial
insurance)
● Productivity tracking in
remote environments
● Case documentation and
audit readiness
Professional Experience:
Molina Remotely – Community Service Department May 2024 – Nov 2025 Program Coordinator – Prior Authorization
● Reviewed and processed community service referrals, including housing transition navigation, deposit assistance, and tenancy support, ensuring timely access to essential resources.
● Verified member insurance eligibility, benefits coverage, and prior authorization requirements in alignment with payer guidelines.
● Initiated and submitted prior authorization requests, coordinating required clinical documentation, ICD-9/ICD-10, and CPT codes to ensure compliance and accuracy.
● Collaborated closely with Utilization Management (UM) to support members with chronic or complex conditions, forwarding provider documentation for medical review and determination.
● Proactively followed up with payers and physician offices to track authorization status, approvals, and denials, maintaining visibility throughout the approval lifecycle.
● Managed authorization denials, appeals, and retro authorizations, partnering with providers and payer representatives to resolve complex cases efficiently.
● Acted as a liaison between community providers, physician offices, internal departments, and external stakeholders to facilitate timely member support and access to care.
● Conducted outreach to disengaged or disenrolled members, verified demographic details through internal systems, and coordinated with service providers to ensure continuity of care.
● Utilized CRM systems and advanced Microsoft Excel to manage multiple member cases simultaneously with strong attention to detail and organization.
● Supported cross-functional projects requiring coordination of extensive community-based resources across departments.
Centene Healthcare Remotely AZ – Provider Queue Aug 2023 – Apr 2024 Provider Service Coordinator
● Handled high-volume inbound provider calls 30-40, verifying member eligibility, benefits, and Medicare, Medi-Cal HMO & PPO plan details.
● Determined prior authorization requirements and escalated urgent requests to Utilization Management within established turnaround times.
● Coordinated and scheduled peer-to-peer reviews between providers and medical directors to support authorization decisions.
● Verified provider credentials and network participation status (in-network/out-of-network) through provider portals.
● Assisted with benefit, eligibility & insurance related clarification, coverage schedules, and case management requests.
● Coordinated member transportation services for medical, pharmacy, dental, and vision appointments in accordance with advance notice guidelines.
● Maintained detailed case documentation within internal systems to ensure compliance and accurate tracking. SCE Southern California Edison Jul 2022 – May 2023 Solar Review Coordinator
● Reviewed 20- 25 daily referral attachments Via email, directly SCE contractor check attachment status.
● Daily 1-25 forward field engineer: its database, battery (KW), system size. Review the member application requesting solar system verification eligibility.
● Responsible for each SCE contractor region ( county ) load justification engineer review status or approval. University of California Member Service Department Jun 2013 – Nov 2021 UC Coordinator Specialist
● Answered and appropriately directed UC provider 20-25 daily service calls.
● Generate an invoice for members who are responsible for paying out of pocket.
● Monitor the database promptly, checking UC providers' and medical groups' incoming encrypted fax folders for medical services.
● HIPAA guideline protocol: forward medical group records with each member's interaction or transaction
(encrypted) via email.
● Daily 10-20 consent from the member or power of attorney.
● Processed member transfer medical group or primary care physician change.
● Send members a new healthcare ID once generated.
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