Prior Authorization Specialist
- Intake & Review: Receive and review requests for prior authorization, meticulously checking patient demographics, insurance coverage, medical necessity documentation, and scheduled CPT/ICD codes.
- Payer Submission: Initiate, submit, and track authorization requests accurately via payer portals, fax, or phone, adhering strictly to each payer's specific submission guidelines and deadlines.
- Clinical Communication: Collaborate closely with clinical staff (doctors, nurses, medical assistants) to obtain necessary documentation, clinical notes, and physician signatures required for authorization submission and appeals.
- Follow-up & Tracking: Proactively manage the entire PA workflow, conducting timely follow-up with insurance companies to monitor the status of pending authorizations.
- Denial Management: Identify, document, and manage authorizations that are initially denied. Prepare documentation for appeals or peer-to-peer review processes as instructed by the client.
- Documentation & Reporting: Accurately log all authorization status updates, approval numbers, validity dates, and denial reasons in the client's practice management system or tracking tool.
- Compliance & Knowledge: Stay updated on changing payer authorization policies, coverage criteria, and procedure code changes that impact the approval process.
- Productivity & Quality: Meet daily productivity goals and maintain a high quality of authorization accuracy and turnaround time (TAT).
- Experience: 1–3 years of dedicated experience in Prior Authorization, Utilization Review, or Clinical RCM/Denial Management. (Experience with specific specialties like Radiology or Orthopedics is a plus).
- Education: Any graduate or diploma holder.
- RCM/Clinical Knowledge: Strong working knowledge of CPT, ICD-10, and medical necessity criteria. Understanding of different payer types and their specific PA processes.
- Communication: Excellent verbal and written communication skills for professional interaction with U.S. clinical offices and insurance representatives.
- Organizational Skills: Exceptional ability to manage multiple complex cases simultaneously under tight deadlines.
- Persistence: High level of persistence and professionalism required to secure approvals through challenging payer workflows.
- Technical Proficiency: Familiarity with online payer portals, EMR/PM systems, and basic office software.
- Organizational Excellence
- Process Compliance and Accuracy
- Effective Communication and Diplomacy
- Persistence and Follow-Through
- Sense of Urgency
- Shift Timings: Day & Night Shift
- Work Schedule: Sunday & Monday off for day shift, Saturday & Sunday off for night shift (schedule may vary slightly based on client requirements).