Clinical Authorization Specialist

Role & responsibilities

• Prioritization and Prior Approval: Responsible for evaluating the patient's condition, determining the medical necessity, and submitting the necessary documentation to the insurance company for approval ensuring that the proposed treatment or service is covered by the insurance policy before it is performed.
• Medical Necessity Determination: Responsible for providing additional documentation or explanation to support the medical necessity of specific treatments or procedures justifying the necessity of certain medical interventions to ensure proper reimbursement.
• Diagnosis and Treatment Coding: Responsible for assigning appropriate diagnosis codes (ICD-10) and procedure codes (such as Current Procedural Terminology or CPT codes) to accurately represent the patient's condition and the medical services rendered which are necessary for billing and reimbursement purposes.
• Insurance Communication: Liaise with insurance companies to obtain preauthorization, clarify requirements, resolve discrepancies, and ensure timely approval of medical services.
• Clinical Documentation Review: Review clinical notes, test results, and physician documentation
• to ensure completeness and compliance with insurance and regulatory standards.
• Compliance and Quality Assurance: Ensure all prior authorization requests and medical documentation comply with HIPAA regulations, payer guidelines, and internal quality standards.
• Denial Management: Analyze and respond to denied authorization requests by providing additional medical justification or appealing based on medical necessity.
• Record Maintenance: Maintain accurate records of authorization requests, approvals, denials, and correspondence for audit and reference purposes.
• Compliance & Quality Standards: Ensure compliance with HIPAA, payer guidelines, and internal audit standards. Maintain confidentiality of patient information.
• Reporting: Prepare daily/weekly/monthly reports on authorization status, TAT, denials, and approvals. Highlight process gaps and contribute to quality improvement initiatives.

Preferred candidate profile

1. Pharm D, MBBS from India, MBBS from foreign countries like China, Russia, Ukraine etc., BHMS, BAMS,

BDS, MDS, BPT, MPT, MPharmacy, MSC Life Science.

2. Night Shift only

3. Work from Office only

4. MS Office (Word, Excel, Power Point) usage