Prior Authorization

Job Title: Prior Authorization Specialist

Experience Level: 15 years.

Location: Vadodara, Gujarat, India / WFH

Shift Time: US Shift (10-hour shift including a 1-hour break)

Job Overview:

We are looking for a detail-oriented Prior Authorization Specialist to manage end-to-end prior authorization workflows for specialty medical services, procedures, imaging, physical therapy, and medications. The role involves coordinating with clinic staff, healthcare providers, payer portals, and insurance companies to collect documentation, submit authorization requests, track outcomes, and resolve issues that may delay patient care.

Key Responsibilities:

• Initiate, submit, and track prior authorization requests for medical services, procedures, imaging, physical therapy, specialty medications, and other clinic requirements.
• Review patient insurance information, benefits, clinical documentation, diagnosis codes, CPT/HCPCS codes, modifiers, payer requirements, and medical necessity criteria before submission.
• Collect, verify, and organize required documentation, including chart notes, imaging reports, physical therapy notes, operative plans, medical necessity forms, and payer-specific forms.
• Identify missing or incomplete information and coordinate with clinic staff, providers, and internal teams to obtain the required documentation.
• Submit authorization requests accurately and on time through payer portals, fax, phone, and other submission methods.
• Use payer portals such as Availity, Carelon, Turning Point, UHC, Cigna, Aetna, and other payer-specific systems.
• Follow up on pending cases, respond to payer inquiries, check authorization status, escalate delays, and ensure deadlines are met.
• Maintain accurate records of actions, communications, submission details, case numbers, payer responses, and outcomes in internal systems.
• Communicate authorization updates clearly and proactively to internal team members and clinic stakeholders.
• Support denial follow-up, reconsiderations, appeals, and peer-to-peer coordination by organizing documentation and assisting with next steps.
• Identify recurring payer issues, avoidable denials, missing documentation, and workflow gaps, and recommend process improvements.

Qualifications & Skills:

• 1–5 years of experience in prior authorization, medical billing, revenue cycle management, patient access, insurance verification, pharmacy operations, or a related healthcare administrative role.
• Working knowledge of health insurance concepts, including benefits, eligibility, medical necessity, coverage criteria, denials, and appeals.
• Strong attention to detail and ability to manage multiple cases while meeting deadlines and documentation requirements.
• Excellent written and verbal communication skills, including professional phone etiquette when communicating with payers and clinic staff.
• Comfortable working with payer portals, EHRs, spreadsheets, internal dashboards, and productivity tools.
• Ability to learn new payer systems, clinic workflows, and specialty-specific requirements quickly.
• Strong organizational, follow-up, and problem-solving skills.

Preferred Qualifications:

• Experience with payer portals such as Availity, CoverMyMeds, Carelon, Turning Point, UHC Provider Portal, Cigna, Aetna, or similar systems.
• Familiarity with ICD-10, CPT, HCPCS, and modifiers, along with common clinical documentation requirements.
• Experience with EHR or practice management systems such as ModMed, AdvancedMD, Athena, Epic, or similar platforms.