Clinical Authorization Specialist

PractoPulse Healthcare Services Private Limited; Hyderabad; On-site; INR 500,000 - 800,000; Full time

Job summary

PractoPulse Healthcare Services Private Limited is looking for a Clinical Authorization Specialist to evaluate medical necessity and manage insurance documentation. This role demands knowledge of diagnosis coding, insurance communication, and compliance with HIPAA regulations.

The ideal candidate should possess an MBBS or equivalent degree and be comfortable with MS Office. Responsibilities include maintaining accurate records and preparing reports. The position is for Night Shift only and requires working from the office.

Qualifications

• Medical degree required (MBBS or equivalent).
• Experience in insurance prior authorization preferred.
• Familiarity with clinical documentation and coding.

Responsibilities

• Evaluate and submit documentation for insurance approvals.
• Communicate with insurance companies regarding requirements.
• Review clinical notes for compliance.

Skills

Medical coding (ICD-10, CPT)

Insurance communication

Clinical documentation review

Quality assurance

Analytical skills

Education

MBBS or equivalent degree

MSC Life Science

Pharm D

Tools

MS Office (Word, Excel, Power Point)

Job description

JOB 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.
• 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

• MBBS from India, MBBS from foreign countries such as China, Russia, Ukraine, BHMS, BAMS, BDS, MDS, BPT, MPT, MSC Life Science, Pharm D
• Night Shift only
• Work from Office only
• MS Office (Word, Excel, Power Point) usage