Prior Authorization Specialist Healthcare Admin expert

Heather Labine

Westfield, MA• 413-***-**** • *********@*****.***

Professional Summary

Prior Authorization Specialist with 25+ years of experience in healthcare administration, insurance verification, and claims resolution. Proven ability to manage high-volume authorization requests, reduce denials, and ensure timely patient care through efficient coordination with providers and payers. Highly skilled in EMR systems including Cerner, McKesson, and HCHB, with deep knowledge of Medicare, Medicaid, and commercial insurance requirements.

Core Skills

Authorization & Insurance

•Prior Authorizations & Pre-certifications

•Insurance Verification & Eligibility

•Medicare & Medicaid Expertise

•Claims Processing & Appeals

•Denial Resolution

Technical Skills

•Cerner, McKesson, HCHB

•EMR Documentation & Data Entry

•Insurance Portals & Eligibility Systems

Operations & Communication

•High-Volume Call Handling

•Medical Records Review

•Cross-Department Coordination

•Customer Service & Patient Support

•Regulatory Compliance (HIPAA)

Professional Experience

Prior Authorization Specialist (Per Diem)

Baystate Medical Center - Springfield, MA

2023 - Present

•Process high-volume CT and MRI authorization requests, ensuring timely approvals for patient care

•Review clinical documentation to validate medical necessity and support authorization approvals

•Verify patient insurance eligibility and benefits, identifying coverage issues proactively

•Coordinate with physicians, clinical staff, and patients to resolve documentation and scheduling issues

•Maintain strong relationships with providers and insurance representatives to streamline approvals

Authorization Specialist

Care Central VNA & Hospice - Gardner, MA

Sept 2025 - Present

•Manage authorizations, notifications, and pre-certifications for home health and hospice services

•Process and track authorization requests across Medicare, Medicaid, and commercial payers

•Investigate and resolve denied claims, submitting appeals with supporting clinical documentation

•Perform detailed medical reviews to ensure compliance with payer requirements

•Maintain accurate patient and insurance records within EMR systems

•Collaborate with clinical teams to ensure timely and accurate documentation submission

•Handle high call volume while providing clear communication to patients, providers, and insurers

Managed Care Coordinator I Authorization Specialist

Overlook Visiting Nurse Association - Charlton, MA

Jan 2002 - Sept 2025

•Managed full-cycle prior authorization process for home care and hospice services

•Processed large volumes of authorization requests daily across multiple insurance carriers

•Reduced claim denials by identifying issues early and coordinating timely resolutions with payers

•Verified insurance coverage, eligibility, and payer requirements to determine financial responsibility

•Reviewed medical documentation for accuracy, coding compliance, and completeness

•Submitted claims and reconciled EOBs, ensuring accurate billing and reimbursement

•Developed and updated operational procedures for a 5-person department, improving workflow efficiency

•Collaborated with physicians, clinicians, and administrative staff to resolve authorization and billing issues

•Maintained compliance with HIPAA and industry regulations

•Utilized EMR systems (Cerner, HCHB) to manage patient records and authorization tracking

Additional Strengths

•Strong knowledge of medical terminology and procedures

•Expertise in navigating multiple insurance systems simultaneously

•Proven ability to multitask in fast-paced, high-demand environments

•Excellent problem-solving and conflict resolution skills

References

Available upon request

Contact this candidate