- Handle the end-to-end prior authorization process for medical procedures, services, and treatments.
- Verify patient insurance eligibility and benefits before initiating authorization.
- Review insurance policies to determine whether prior authorization is required.
- Submit authorization requests through insurance portals, payer websites, fax, or phone.
- Collect and validate required clinical and patient information for authorization submission.
- Coordinate with providers, clinical teams, and insurance companies for missing documentation.
- Follow up with insurance companies on pending authorization requests.
- Track authorization status and maintain accurate records in the relevant system.
- Communicate authorization approvals, denials, and additional documentation requirements to the appropriate teams.
- Work on authorization denials and re-submissions where applicable.
- Ensure authorizations are obtained within payer-specific timelines to avoid service delays and potential claim denials.
- Maintain accurate documentation of authorization numbers,
effective dates, expiration dates, and approved services.
- Identify authorization-related issues that may impact claims processing and reimbursement.
- Meet defined productivity, quality, accuracy, and turnaround-time (TAT) targets.
- Follow HIPAA, payer, client, and company compliance requirements.
- Escalate complex authorization issues to the appropriate team or supervisor.
- Maintain confidentiality of patient and healthcare information.Role &
Preferred candidate profile
- Candidates with 1-4 years of experience in US Healthcare RCM, particularly Prior Authorization, Eligibility, Insurance Verification, or related processes.
- Experience working with US insurance payers and provider offices will be preferred.
- Candidates with knowledge of medical terminology and US healthcare processes are preferred.
- Positive communication skills and willingness to meet process targets.