Eligibility & Authorization Specialist

Location: DHA Phase 8, Lahore [Onsite]

Employment Type: Full-time

Work Timing: 05 PM – 02 AM Pakistan Time (US Business Hours)

Job Overview

Topline Resource Group (TLRG) is seeking a dedicated Eligibility & Authorization Specialist to manage the critical front-end operations for our US-based healthcare clients. This role is focused entirely on securing the financial foundation of the practice by ensuring every patient has active coverage and every procedure has the required clinical approval before services are rendered.

Key Responsibilities

• Verify patients' insurance coverage and eligibility in real-time to ensure policies are active and services are covered on the specific Date of Service (DOS).
• Obtain pre-authorizations from insurance companies for medical procedures and treatments.
• Communicate directly with patients regarding their insurance status, coverage specifics, and any required actions or out-of-pocket responsibilities.
• Maintain accurate and meticulous records of insurance verifications and authorizations, including representative names and unique reference numbers for audit trails.
• Collaborate with healthcare providers to ensure all necessary clinical information, physician notes, and CPT/ICD-10 codes are obtained for successful pre-authorizations.
• Monitor and follow up on pending authorizations daily to ensure timely processing and stay within the 7–10 day payer response window.
• Analyze insurance benefits to identify exact copays, unmet deductibles, and co-insurance percentages to ensure accurate front-end collections.
• Identify if the provider is in-network or out-of-network and determine if specific plan tiers (HMO/EPO) require a PCP referral before the visit.
• Stay up to date with insurance policies, CMS regulations, and HIPAA guidelines to ensure 100% compliance across all US healthcare accounts.
• Track and manage KPIs, including the clean claim rate and authorization turnaround time, to reduce AR aging and increase collection rates.

Required Qualifications

• 3+ years of experience in US Medical Billing, specifically focused on Front-End operations (Eligibility and Authorizations).
• Expert-level familiarity with CPT, ICD-10, and HCPCS codes and their specific relationship to authorization requirements.
• Deep understanding of US insurance plans, including Medicare, Medicaid, HMO, PPO, and Commercial plans.
• Hands-on experience with EHR/EMR systems, Practice Management software, and major US payer portals (Availity, Navinet, etc.).
• Excellent verbal and written English communication skills for professional interaction with US insurance companies and clinical teams.
• Strong analytical ability to interpret Verification of Benefits (VOB) reports and payer medical necessity criteria to resolve issues before service delivery.

Pay: Rs100,000.00 - Rs125,000.00 per month

Experience:

• eligibility & authorization: 2 years (Required)

Work Location: In person