Prior Authorization Specialist (US Healthcare)

Job Summary :

The Prior Authorization Specialist is responsible for obtaining insurance approvals for medical procedures, diagnostic tests, and medications by coordinating with healthcare providers, insurance companies, and patients. This role ensures compliance with payer requirements while minimizing delays in patient care.

Key Responsibilities :

• Submit and manage prior authorization requests to US insurance payers (Medicare, Medicaid, and commercial plans)
• Review medical documentation to ensure completeness and medical necessity
• Verify patient insurance eligibility and benefits
• Communicate with physicians, nurses, and clinical staff to obtain required clinical information
• Follow up on pending authorizations and appeals on time
• Handle authorization denials and initiate appeals when necessary
• Maintain accurate records in EMR/EHR systems
• Ensure compliance with HIPAA and payer-specific guidelines
• Track authorization turnaround times and report status updates to stakeholders.

Required Qualifications :

• 1–3 years of experience in US healthcare prior authorization, medical billing, or revenue cycle management
• Strong knowledge of US insurance plans, CPT, ICD-10, and HCPCS codes
• Familiarity with Medicare, Medicaid, and commercial payer policies
• Experience working with EMR/EHR systems
• Excellent verbal and written communication skills.

Preferred Qualifications :

• Certification such as CPC, CPB, or equivalent (AAPC preferred)
• Experience in specialty practices (e.g., Pain Management, cardiology, orthopedics, radiology, oncology)
• Experience handling peer-to-peer reviews and appeals

Skills & Competencies :

• Attention to detail and strong organizational skills
• Ability to manage multiple authorization requests simultaneously
• Problem-solving and analytical thinking
• Time management and a deadline-driven work ethic
• Customer service mindset with a patient-focused approach

Work Environment :

• Office-based
• Full-time
• US business hours preferred

Job Type: Full-time

Pay: ₹100,000.62 - ₹445,288.63 per year

Benefits:

• Health insurance

Work Location: In person