Prior Auth/EVBV -QA (21 -Jan-26)

Eclat-Health-Solutions-4; Hyderabad; On-site; INR 500,000 - 700,000; Full time

Job summary

Eclat-Health-Solutions-4 is seeking a candidate for the role of QA in Prior Authorization (PA) and Eligibility Verification & Benefits Validation (EVBV) in Hyderabad, India. This position involves auditing healthcare revenue cycle processes to ensure compliance and improve workflow efficiency.

The ideal candidate should possess strong analytical skills, a solid understanding of HIPAA regulations, and experience with EDI transactions. Excellent communication skills are essential for interacting effectively within a team and with external stakeholders.

Qualifications

• Strong defect analysis and problem-solving skills.
• Excellent verbal and written communication skills.
• Understanding of regulatory compliance requirements.

Responsibilities

• Review PA/EVBV processes for accuracy and compliance.
• Ensure correct validation of patient insurance coverage.
• Manage the submission and approval stages of prior authorization.
• Validate data integrity and ensure accuracy in transactions.
• Perform root cause analysis for quality issues and denials.
• Create quality reports and support process improvements.

Skills

Quality Auditing

Data Integrity Validation

Root Cause Analysis

Communication Skills

Compliance Knowledge (HIPAA)

Tools

EDI Transactions (270/271, 278)

RCM Software

Job description

APrior Authorization (PA) & EVBV (Eligibility Verification & Benefits Validation) QA Job involvesauditing healthcare revenue cycle processes (like EVBV via EDI 270/271 & PA via EDI 278/portals) to ensure accuracy, compliance with SLAs, payer rules (CPT/ICD codes), and data integrity, focusing onquality control , root cause analysis for denials/failures, and improving workflow efficiency for billing and patient care. Key tasks include reviewing patient data, verifying insurance, submitting requests, following up on statuses (approvals/denials), and identifying process gaps for training and improvement.

Core Responsibilities

• Quality Auditing:Reviewing PA/EVBV processes for accuracy, compliance, and adherence to timelines (TAT/SLA).
• Eligibility & Benefits:Ensuring correct validation of patient insurance (270/271), coverage, co-pays, and benefits.
• Prior Authorization Workflow:Gatekeeping the submission, tracking, approval, denial, and appeal stages, often using EDI 278 or payer portals.
• Data & Integration:Validating data integrity across systems and ensuring accuracy in EDI/API transactions.
• Issue Resolution:Performing root cause analysis for denials, discrepancies, and quality issues, and working on appeals.
• Reporting & Improvement:Creating quality reports, providing feedback to operations/training, and supporting process enhancements.
• Technical:Familiarity with EDI transactions (270/271, 278), payer portals, and RCM software.
• Analytical:Strong defect analysis, problem-solving, and critical thinking.
• Communication:Excellent verbal/written skills for interacting with providers, payers, and internal teams.
• Compliance:Understanding of HIPAA and regulatory requirements.