JENIFFER ROSALES
Ontario,CA
Summary
Dependable Prior Authorization Specialist experienced in managing administrative tasks in fast-paced environments. Achieved operational efficiency by effectively communicating approval and denial details to healthcare providers and members while ensuring compliance with formulary and utilization management guidelines. Focused on obtaining prior authorization information for patients and improving pharmacy operations through collaboration with clinical teams.
Overview
1
1
Certification
24
24
years of professional experience
Work History
Prior Authorization Pharmacy Technician
Blue Shied of California
Long Beach
11.2025 - Current
- Reviewed prior authorization requests for Blue Shield of California pharmacy benefits.
- Verified member eligibility and prescription coverage rules.
- Processed physician submissions for medication approval decisions.
- Communicated denial and approval details to providers and members, facilitating timely decision-making in patient care.
- Escalated incomplete cases for clinical review and follow-up.
- Applied formulary and utilization management guidelines during reviews.
- Supported pharmacy operations with accurate documentation and case updates.
- Researched drug formularies and therapeutic alternatives during the authorization process.
- Assessed non-formulary drugs for cost effectiveness against formulary drugs, supporting optimal medication choices for patients.
- Ensured that all required documents were obtained before submitting a request for approval of medications requiring preauthorization.
- Reviewed physician's office notes for medication history and allergies to ensure safety of patients.
- Collaborated with team members, technicians and pharmacists to prioritize and complete orders.
- Ensured compliance with state and federal pharmacy laws and regulations, safeguarding operational integrity and patient safety.
Prior Authorization Specialist
Owl Rexall Drug Pharmacy
Glendora, California
03.2003 - 05.2025
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Facilitated communication between providers, payers and health plans regarding prior authorization processes.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Researched clinical criteria and determined eligibility for requested services based on plan provisions.
- Consulted with insurance company representatives to complete claims processing, resolve concerns, and reconcile payments.
- Analyzed trends in denials and approvals to pinpoint areas for departmental improvement.
- Managed the appeals process to resolve authorization denials.
Education
Bachelor Of Pharmacy - Pharmacy
Philippine Women's University
PhilippinesSkills
- Prior authorization
- Authorization processing
- Claim processing
- Claims processing experience
- Insurance verification
- Benefit verification
- Benefit coverage
- Pharmacy benefit management
- Formulary review
- Prescription Processing
- Order verification
- Order Verification
- Refill fulfillment
- Prior authorization
- Precertification requirements
- Insurance procedures
- Practitioner verification
- Patient interaction
- Documentation management
- Referral Coordination
- Effective communication skills
- Formulary review
- Benefit verification
Certification
• California Registered Pharmacy Technician | License #TCH 49356
Timeline
Prior Authorization Pharmacy Technician
Blue Shied of California
11.2025 - Current
Prior Authorization Specialist
Owl Rexall Drug Pharmacy
03.2003 - 05.2025
Bachelor Of Pharmacy - Pharmacy
Philippine Women's University