clinical authorization specialist - Hyderabad
18 hours ago
Job description
Job DescriptionJOB ROLE :
CLINICAL AUTHORIZATION SPECIALIST
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 profile1.
MBBS from India, MBBS from foreign countries like China, Russia, Ukraine etc., BHMS, BAMS,BDS, MDS, BPT, MPT, MSC Life Science, Pharm D2.
Night Shift only3. Work from Office only4. MS Office (Word, Excel, Power Point) usageRole:
Healthcare & Life Sciences - Other
Industry Type:
Analytics / KPO / Research
Department:
Healthcare & Life Sciences
Employment Type:
Full Time, Permanent
Role Category:
Healthcare & Life Sciences - Other
Education
UG:
Bachelor of Physiotherapy in Any Specialization, MBBS - Bachelor of Medicine and Bachelor of Surgery in Any Specialization, BHMS - Bachelor of Homeopathic Medicine and Surgery in Any Specialization, BAMS - Bachelor of Ayurvedic Medicine and Surgery in Any Specialization, BDS - Bachelor of Dental Surgery in Any Specialization
PG:
M.Pharma in Any Specialization, Medical-MS/MD in Any Specialization, MDS in Any Specialization, MS/M.Sc(Science) in Any Specialization
Doctorate:
Ph.
D/Doctorate in Any Specialization
Key Skills
Skills highlighted with '' are preferred keyskills
Medical OncologyOncologyPrior AuthorizationUS HealthcareAnatomy
HealthcarePhysiologyInsurance Verification
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