Job Summary (List Format) Prior Authorization Specialist (Dental & Medical Crossover Authorizations)

1. Prior Authorization Processing
- Submit dental prior authorization requests to commercial and Medicaid payers.
- Process medical crossover cases for dental procedures billed under medical insurance.
- Attach and review required documentation (radiographs, narratives, clinical records, etc.).
- Confirm appropriate code sets (CDT, CPT, ICD-10) before submission.
- Track authorization status, payer reference numbers, and next action dates in ClickUp.
- Contact payers for status updates or when cases exceed turnaround times.
- Record and communicate authorization results and approvals to the practice promptly.

2. Eligibility & Benefits Verification
- Verify active dental and medical insurance coverage prior to treatment.
- Confirm plan types, effective dates, and coordination of dual coverage.
- Review plan benefits, restrictions, and limitations affecting treatment plans.
- Identify and communicate coverage issues to practice staff before appointments.

3. Denial Management & Appeals
- Analyze authorization denials to determine root causes (missing documentation, coding issues, medical necessity, etc.).
- Prepare and submit appeals with supporting clinical documentation as needed.
- Follow up on denied or appealed cases within payer timeframes.
- Escalate complex or persistent denials to the team lead.
- Identify patterns to improve first-pass approval rates.

4. Communication & Reporting




- Use HIPAA-compliant ClickUp chat group for all communications with practice staff.
- Maintain clear, accurate, and auditable case notes.
- Provide daily end-of-shift summaries of case statuses (submitted, approved, pending, follow-up, blocked).
- Participate in onboarding and process training calls.
- Maintain comprehensive payer-specific notes and authorization process documentation.

5. Required Qualifications
- Clinical or allied healthcare degree (Dentistry, Pharmacy, Nursing, Physiotherapy, or similar).
- Minimum 1 year of relevant experience (prior authorization, dental/medical insurance, or healthcare revenue cycle with US payers).
- Working knowledge of CDT, CPT, and ICD-10 codes.
- Understanding of dental-to-medical crossover billing and authorizations.
- Solid English communication (written and verbal); experience with payer communications.
- Attention to detail in reviewing clinical documentation.
- Ability to work independently, manage multiple cases, and meet deadlines.
- Willingness to work US Eastern business hours from onsite delivery center.

6. Preferred Qualifications
- Experience with dental practice management systems (Dentrix, Eaglesoft, Open Dental, etc.).
- Background in academic, hospital-based, or specialty dental practices.
- Experience with state Medicaid programs and dental Medicaid authorizations.
- Familiarity with oral surgery, sedation, trauma, or sleep appliance authorizations.
- Experience using ClickUp or similar task management tools.
- Prior exposure to handling denials, appeals, and medical necessity documentation.

📌 Prior Authorization Specialist – Dental & Medical Crossover Authorizations (Hyderabad)
🏢 Staffingly
📍 Hyderabad