Role Overview

We are seeking a QA Associate - Prior Authorization to join our team and ensure the quality, accuracy, and compliance of our prior authorization processes. In this role, you will be responsible for reviewing, auditing, and improving prior authorization workflows, with a focus on validating that all prior authorization requests are processed in accordance with industry guidelines and company standards. You will work closely with healthcare teams, insurance payers, and cross-functional stakeholders to ensure that our prior authorization system runs efficiently, delivers high-quality outcomes, and supports patient care.

Responsibilities:

● Quality Auditing: Perform regular audits of prior authorization requests to ensure they meet required medical necessity criteria and insurance guidelines.

● Process Improvement: Identify opportunities to enhance the quality and efficiency of the prior authorization process and collaborate with the team to implement improvements.

● Documentation Review: Ensure that all prior authorization documentation is complete, accurate, and compliant with healthcare regulations (e.g., HIPAA, payer-specific requirements).

● Compliance Monitoring: Monitor the accuracy and compliance of prior authorization requests in line with internal policies and external regulations.

● Collaboration with Teams: Work closely with healthcare providers, insurance payers, and internal teams to resolve any issues, denials, or discrepancies in prior authorization requests.

● Reporting & Tracking: Maintain detailed records of audits, tracking the outcomes of quality assurance checks, and report findings to management.

● Trend Analysis: Identify recurring issues or bottlenecks in the prior authorization process and work with the team to address systemic challenges.

● Continuous Improvement:



Support ongoing training for the team to ensure understanding and adherence to quality standards in prior authorization practices.

● Feedback & Recommendations: Provide feedback to internal teams to improve the accuracy, completeness, and efficiency of prior authorization submissions.

● Regulatory Compliance: Ensure compliance with healthcare regulations such as HIPAA, SOC 2, and any payer-specific guidelines or standards during all stages of prior authorization processes.

Qualifications

● Experience: Minimum of 0-2 years of experience in prior authorization processes, healthcare administration, or quality assurance in a regulated environment.

● Knowledge of Healthcare & Insurance: Strong understanding of insurance policies, reimbursement processes, medical necessity criteria, and regulatory standards affecting prior authorizations.

● Attention to Detail: High level of attention to detail and the ability to accurately review and process complex documentation.

● Process-Oriented: Strong ability to follow defined procedures and standards while identifying areas for improvement.

● Technical Proficiency: Proficiency in using EMR systems (e.g., Epic, Cerner) and prior authorization platforms. Familiarity with QA tracking tools and reporting systems , Cover My meds ,Evicore.

● Communication Skills: Excellent written and verbal communication skills with the ability to collaborate effectively with healthcare teams and external stakeholders.

● Problem-Solving: Robust analytical and problem-solving skills, able to identify issues and propose practical solutions.HIPAA & Compliance Knowledge: Understanding of HIPAA regulations and healthcare compliance standards.

● Preferred Certifications: Certification in Healthcare Administration, Medical Coding, or Quality Assurance is a plus.

📌 QA Associate - Prior Authorization (Bengaluru)
🏢 Risa
📍 Bengaluru