Ophthalmology Prior Authorization Specialist

Remote | Full-Time | Monday–Friday | 10:00 AM–6:00 PM U.S. Eastern Time

Position Overview

We are a comprehensive ophthalmology and ophthalmic surgery practice seeking an experienced Ophthalmology Prior Authorization (PA) Specialist to take ownership of insurance authorizations, benefits verification, medication approvals, and related administrative workflows.

This is not a position for someone learning ophthalmology PAs for the first time. The successful candidate should already understand ophthalmology terminology, common procedures, injectable and implantable medications, medical-benefit versus pharmacy-benefit authorization workflows, and how to communicate effectively with insurance companies, pharmaceutical support programs, clinical staff, physicians, and patients.

Prior authorization work is expected to occupy 25%–50% of the employee's full-time workload (0.25–0.5 FTE). When authorization work is caught up, the employee is expected to assist with chart-review, patient-communication, and task-management responsibilities.

The objective of this position is that no medically necessary treatment, procedure, injection, surgery, diagnostic service, or medication should be delayed because an authorization was not identified, submitted, followed up on, documented, or completed properly.

Required Working Hours and Availability

This is a full time remote position with required working hours of:

M-F 10:00 AM–6:00 PM U.S. Eastern Time

The employee must adjust their local working hours as necessary when the United States transitions between Eastern Standard Time and Eastern Daylight Time.

During these eight hours, the employee must be:

- Actively working and reachable.
- Available for Google Meet upon request.
- Willing and able to appear on camera with webcam turned on during working hours.
- Available to meet with management, physicians, billing personnel, schedulers, or other team members during the scheduled workday as needed.
- Available for live screen sharing during business hours for collaboration, training, workflow review, troubleshooting, quality assurance, or management oversight.
- Capable of placing calls to U.S. insurance companies, patients, pharmacies, specialty pharmacies, pharmaceutical support programs, and other organizations.

The employee must maintain a professional and reliable remote-work environment with reliable high-speed internet, a functioning webcam, headset/microphone. A Dialpad account to place and receive U.S. telephone calls will be provided.

Primary Responsibility: Ophthalmology Prior Authorizations

The Prior Authorization Specialist will be responsible for managing the authorization process from beginning to end.

Responsibilities include:

- Determining whether authorization is required before a procedure, surgery, injection, implant, medication, or diagnostic service is performed.
- Confirming insurance eligibility and benefits.
- Identifying whether a service is processed under the patient's medical benefit, pharmacy benefit, or specialty-pharmacy benefit.
- Determining applicable payer medical policies, step-therapy requirements, preferred products, site-of-care requirements, quantity limits, frequency limitations, and documentation requirements.
- Submitting PA requests by telephone, by fax, or through payer-specific portals.
- Uploading clinical notes, diagnostic testing, medication history, treatment failures, photographs, imaging, visual-field results, OCT results, operative plans, and other supporting documentation.
- Following authorization requests until a final determination is obtained.
- Calling insurance companies when an electronic authorization cannot be completed.
- Calling insurance companies to obtain, investigate, expedite, or follow up on prior authorizations is a required part of this position.
- Obtaining reference numbers and documenting all telephone conversations.
- Tracking pending authorizations and proactively following up rather than waiting for the payer to contact the practice.
- Identifying authorization denials immediately.
- Obtaining denial letters and determining the specific reason for denial.
- Coordinating reconsiderations, appeals, peer-to-peer reviews, or additional documentation when appropriate.
- Escalating urgent or complex authorization issues to appropriate manager or physician.
- Communicating authorization status to clinical staff and surgery/injection schedulers.
- Documenting authorization numbers, effective dates, expiration dates, approved units, approved medication, approved CPT/HCPCS codes, servicing provider, servicing location, and any payer-specific limitations.
- Confirming that an authorization matches the planned service before patient is treated.
- Preventing avoidable denials caused by incorrect CPT codes, HCPCS codes, diagnosis codes, dates of service, location, units, laterality, medication, or provider information.

Ophthalmology Experience Required





Candidates should be familiar with authorization workflows involving a broad range of ophthalmic services.

Retina and Intravitreal Medications

The employee should understand the authorization and benefits-investigation process for intravitreal medications used for conditions such as wet AMD, diabetic macular edema, diabetic retinopathy, retinal vein occlusion, and geographic atrophy.

Examples include:

- EYLEA® / aflibercept
- EYLEA HD® / aflibercept 8 mg
- VABYSMO® / faricimab
- Avastin® / bevacizumab when used ophthalmically
- Other retina medications introduced into the practice or required by payer formularies

The specialist should understand issues including:

- Buy-and-bill versus specialty-pharmacy acquisition.
- Medical-benefit versus pharmacy-benefit coverage.
- Payer-preferred anti-VEGF agents.
- Step therapy.
- Required previous treatment failures.
- Approved dosing intervals.
- Quantity and unit authorization.
- Loading versus maintenance dosing.
- Switching agents.
- Bilateral treatment considerations.
- Authorization expiration and renewal.
- Coordination between insurance authorization and pharmaceutical benefits investigation.

Glaucoma Procedures and Medications

The employee should understand common glaucoma authorization workflows involving services such as:

- Selective Laser Trabeculoplasty (SLT)
- Laser Peripheral Iridotomy
- Glaucoma drainage procedures
- Goniotomy
- Trabeculectomy
- Glaucoma drainage implants
- Cataract surgery combined with glaucoma procedures
- MIGS procedures such as iStent, Hydrus, and other minimally invasive glaucoma surgery technologies
- Intracameral or implantable glaucoma medications

Examples of drug/implant authorization workflows may include:

- DURYSTA®
- iDose® TR
- Other sustained-release glaucoma treatments

Cataract and Anterior Segment Surgery

Depending upon the patient's insurance plan, authorization or pre-certification may be necessary for services including:

- Standard cataract extraction with intraocular lens implantation.
- Complex cataract surgery.
- Cataract surgery combined with glaucoma procedures.
- Certain secondary intraocular lens procedures.
- IOL exchange or repositioning.
- Anterior-segment reconstruction.
- Corneal transplantation.
- DMEK, DSEK/DSAEK, penetrating keratoplasty, and other corneal procedures.
- Corneal cross-linking.
- Pterygium surgery.
- Amniotic membrane placement when subject to payer medical-necessity requirements.

The employee should understand that requirements vary considerably by payer and should verify rather than assume that a procedure does or does not require authorization.

Ophthalmic Laser Procedures

Depending upon the payer, authorization or notification requirements may apply to procedures including:

- YAG posterior capsulotomy.
- Selective Laser Trabeculoplasty.
- Laser Peripheral Iridotomy.

Oculoplastic and Functional Eyelid Procedures

The employee should understand the particularly documentation-intensive authorization requirements commonly associated with functional oculoplastic surgery, including:

- Functional upper-eyelid blepharoplasty.
- Ptosis repair.
- Brow ptosis repair.
- Ectropion repair.
- Entropion repair.
- Eyelid lesion procedures where applicable.
- Other reconstructive or medically necessary oculoplastic procedures.

Ophthalmic Drugs and Specialty Medications

The specialist may also be responsible for pharmacy-benefit prior authorizations for ophthalmic medications such as:

- Prescription dry-eye medications.
- Anti-inflammatory ophthalmic medications.
- Glaucoma drops requiring step therapy.
- Brand-name medications when generic alternatives have failed.
- Immunomodulatory medications.

This requires familiarity with documenting medication failures, contraindications, intolerance, clinical rationale, and step-therapy exceptions.

Pharmaceutical Manufacturer and Patient-Support Portals

A strong candidate should have experience using pharmaceutical manufacturer programs for benefits investigation, prior-authorization support, copay assistance, patient assistance, reimbursement support, and specialty-drug coordination.

Examples encountered in ophthalmology may include:

- EYLEA4U® for EYLEA/EYLEA HD support.
- iDose Care Connect® for iDose TR.
- Genentech Ophthalmology Access Solutions and related support resources for Genentech ophthalmic products such as VABYSMO and other applicable therapies.
- Manufacturer support programs for DURYSTA and other glaucoma pharmaceuticals.

Responsibilities may include:

- Submitting benefits investigations.
- Reviewing medical and pharmacy coverage.
- Obtaining reimbursement information.
- Coordinating prior-authorization support.
- Tracking enrollment and case status.




- Communicating with manufacturer reimbursement specialists.
- Uploading required forms and clinical documentation.
- Coordinating documentation with the treating physician and billing department.

Authorization Tracking and Accountability

Every authorization must be tracked from initiation through completion.

Pending authorizations must be actively worked. Simply submitting an authorization and waiting indefinitely for a response is not acceptable.

Remaining 50%–75% of the Position: Administrative Support

Prior authorization work is anticipated to represent approximately 0.25–0.5 FTE depending upon practice volume.

The remainder of the employee's scheduled working hours will be used to support other practice operations.

Responsibilities may include:

- Asana Task Management
- Chart review
- Direct Patient Communication: The employee must be comfortable communicating directly with patients by telephone or approved electronic communication.

Examples include:

- Requesting updated insurance cards.
- Requesting pharmacy-benefit information.
- Obtaining prescription insurance information.
- Clarifying the patient's primary and secondary insurance.
- Requesting demographic information.
- Informing patients that an authorization is pending.
- Coordinating information needed for specialty medication processing.
- Discussing nonclinical administrative requirements.
- Helping patients communicate with specialty pharmacies or manufacturer support programs.
- Obtaining information necessary for insurance or authorization processing.

The employee should communicate professionally and courteously while recognizing that clinical questions must be escalated to appropriate clinical personnel.

Telephone Work Is Mandatory

This is not an electronic-portal-only position.

The employee must be willing to call insurance companies directly when necessary.

Candidates who are uncomfortable spending significant time on the telephone with U.S. insurance companies should not apply.

Required Qualifications

Applicants should have:

- Prior professional experience performing ophthalmology prior authorizations.
- Strong knowledge of ophthalmology terminology and procedures.
- Experience with medical-benefit authorizations.
- Experience with pharmacy-benefit prior authorizations.
- Experience with injectable or physician-administered ophthalmic drugs strongly preferred.
- Familiarity with retina medication authorization strongly preferred.
- Familiarity with glaucoma, cataract, and ophthalmic surgery authorization strongly preferred.
- Experience navigating multiple U.S. insurance portals.
- Experience communicating directly with U.S. insurance companies.
- Excellent spoken and written English.
- Strong telephone communication skills.
- Ability to read and understand ophthalmology clinical documentation.
- Ability to work independently and investigate unfamiliar payer requirements without constant supervision.
- Excellent organizational skills.
- High attention to detail.
- Ability to manage a large number of simultaneously pending cases.
- Comfort working with spreadsheets, web portals, EHR systems, Google Workspace, and task-management software.
- Ability to learn our EHR and practice-management systems.
- Experience with Asana is helpful but not required.

Remote Work and Technology Requirements

The employee must have:

- Reliable high-speed internet.
- A modern computer capable of handling multiple browser-based healthcare applications simultaneously.
- A functioning webcam.
- A reliable microphone/headset.
- A professional work environment suitable for patient and insurance-company calls.
- Ability to screen share at any point during scheduled working hours.
- Ability to participate in video meetings with the camera on.
- Ability to access secure practice systems using required authentication and security tools.

Ideal Candidate

The ideal candidate is someone who sees an authorization problem and takes ownership of solving it. We are looking for someone who does not stop at: "The portal says pending."

Instead, the right person asks:

- Why is it pending?
- Does the insurer need additional records?
- Can I call and obtain a decision?
- Is the requested medication non-preferred?
- Is step therapy required?
- Is the authorization under the medical or pharmacy benefit?
- Does the drug need to come from a specialty pharmacy?
- Did we request the correct medication, units, provider, location, and dates?
- Is there a manufacturer reimbursement hub that can assist?
- Does the physician need to complete a peer-to-peer?
- What needs to happen next to prevent the patient's treatment from being delayed?

We are seeking an individual who will own the problem through resolution, document the result clearly, communicate it to the appropriate team members, and then move on to the next priority without requiring constant supervision.

Applicants without meaningful ophthalmology prior-authorization experience should not apply.

Pay: ₹60,000.00 - ₹70,000.00 per month

Benefits:

- Paid sick time
- Paid time off
- Work from home

Work Location: Remote

📌 Prior Authorization Specialist (India)
🏢 Bespoke Ophthalmics
📍 India