Prior Authorization Analyst

Prior Authorization Specialist

Job Summary

The Prior Authorization Specialist is responsible for obtaining, verifying, and documenting prior authorizations from insurance providers for medical services and procedures. This role ensures all required approvals are secured in a timely manner to prevent service delays, claim denials, and revenue loss. The Specialist acts as a liaison between providers, patients, and insurance companies to streamline the authorization process and ensure compliance with payer requirements.

Key Responsibilities

Authorization Request Management :

Initiate and follow up on prior authorization requests for medical services, diagnostic tests, and procedures with insurance companies.

Insurance Communication :

Coordinate with insurance providers to verify the necessity and coverage of requested services.

Clinical Information Gathering :

Collect and submit necessary medical documentation (e.g., clinical notes, test results) to support authorization requests.

Timely Follow-Up :

Track authorization requests to ensure timely approvals and address any denials or pending issues proactively.

Documentation & Record-Keeping :

Maintain accurate and complete records of all authorization requests, approvals, and denials in accordance with organizational standards.

Coordination with Providers :

Work closely with physicians, clinical staff, and scheduling teams to obtain required information for submission to payers.

Denial Management :

Identify reasons for authorization denials and work to resolve issues or submit appeals as needed.

Policy & Coverage Verification :

Confirm insurance plan requirements for authorizations, including coverage limitations, medical necessity criteria, and pre-certification rules.

Payer Portal Utilization :

Access and navigate payer portals (Medicare, UHC, BCBS, Availity, Trizetto, etc.) to submit and track prior authorization requests.

Compliance :

Ensure all authorizations are obtained in compliance with payer regulations and organizational policies.

Skills & Qualifications

Graduation in any stream.

Strong understanding of insurance authorization processes, payer requirements, and medical necessity criteria.

Knowledge of payer portals such as Medicare (Noridian), UHC, BCBS, Availity, and Trizetto.

Experience with prior authorization workflows in a healthcare environment.

Familiarity with insurance plan types (HMO, PPO, EPO, POS) and coverage policies.

Excellent organizational and follow-up skills to manage multiple authorization requests simultaneously.

Strong communication skills to coordinate between providers, patients, and insurance companies.

Attention to detail and ability to interpret insurance policies and medical documentation.

Minimum of 2 years of experience in prior authorization (Physician Billing) or related healthcare roles.

Interested Candidates please contact us on hanand@nath-mds.com / asood@nath-mds.com / +91 7988003159

• Immediate joiners welcomed = Bonus - 10000