Job Description: Prior Authorization – HB QA

Position: Quality Analyst (QA) – Prior Authorization

Process: Hospital Billing (HB) – US Healthcare RCM

Experience: 4–8 years in US Healthcare RCM, including relevant Prior Authorization QA experience

Job Summary

We are looking for an experienced Prior Authorization – HB Quality Analyst to monitor the quality of hospital prior authorization processes, ensure compliance with payer requirements, identify process gaps, and drive continuous improvement in quality and productivity.

Key Responsibilities
Perform quality audits on Hospital Billing (HB) Prior Authorization transactions.
Review authorization requests for accuracy, completeness, and compliance with payer guidelines.
Validate patient demographics, insurance eligibility, medical necessity requirements, CPT/HCPCS codes, diagnosis codes, and authorization details, as applicable.
Verify authorization status, approved service details, validity dates, units, and payer-specific requirements.
Identify errors, process deviations, and documentation gaps, and provide timely feedback to associates.
Conduct root cause analysis (RCA) for recurring errors and implement corrective and preventive actions.
Prepare and maintain quality reports,



audit findings, and performance dashboards.
Conduct calibration sessions with Operations and Training teams to ensure consistent quality standards.
Support process training, refresher sessions, and quality improvement initiatives.
Monitor quality trends and recommend actions to improve accuracy, compliance, and turnaround time.
Ensure adherence to client requirements, SOPs, HIPAA guidelines, and internal quality standards.

Required Skills and Qualifications
Robust experience in US Healthcare RCM, specifically Hospital Billing (HB) Prior Authorization.
Hands-on experience in quality auditing and feedback delivery.
Positive understanding of US insurance plans, payer guidelines, authorization workflows, and medical necessity requirements.
Knowledge of CPT/HCPCS codes, ICD-10 diagnosis codes, and authorization-related documentation.
Experience with quality metrics, sampling methodologies, RCA, and corrective action plans.
Solid analytical, communication, and reporting skills.
Proficiency in MS Excel and quality tracking tools.
Ability to work independently and meet quality and productivity targets.

📌 Prior Authorization Qa Hospital Billing Mumbai
🏢 Eclat Health Solutions
📍 Mumbai