Prior Authorization QA - Hospital Billing (Mumbai)

ECLAT Health Solutions; Mumbai; On-site; INR 600,000 - 1,200,000; Full time

Job summary

ECLAT Health Solutions in Mumbai is seeking an experienced Prior Authorization – HB Quality Analyst to monitor the quality of hospital HB-PA processes, ensure payer compliance, and drive improvements in accuracy and turnaround time. You will perform quality audits, review authorization requests, validate demographics, eligibility, CPT/HCPCS and diagnosis codes, and report findings with actionable feedback.

This full-time role requires 4–8 years in US Healthcare RCM, strong analytical ability,

Qualifications

• Strong experience in US Healthcare RCM, specifically Hospital Billing (HB) Prior Authorization.
• Hands-on experience in quality auditing and feedback delivery.
• Good understanding of US insurance plans, payer guidelines, authorization workflows, and medical necessity requirements.
• Knowledge of CPT/HCPCS codes, ICD-10 diagnosis codes, and authorization‑related documentation.
• Experience with quality metrics, sampling methodologies, RCA, and corrective action plans.

Responsibilities

• Perform quality audits on Hospital Billing (HB) Prior Authorization transactions.
• Review authorization requests for accuracy, completeness, and compliance with payer guidelines.
• Validate patient demographics, insurance eligibility, medical necessity requirements, CPT/HCPCS codes, diagnosis codes, and authorization details, as applicable.
• Verify authorization status, approved service details, validity dates, units, and payer-specific requirements.
• Identify errors, process deviations, and documentation gaps, and provide timely feedback to associates.
• Conduct root cause analysis (RCA) for recurring errors and implement corrective and preventive actions.
• Prepare and maintain quality reports, audit findings, and performance dashboards.
• Conduct calibration sessions with Operations and Training teams to ensure consistent quality standards.
• Support process training, refresher sessions, and quality improvement initiatives.
• Monitor quality trends and recommend actions to improve accuracy, compliance, and turnaround time.
• Ensure adherence to client requirements, SOPs, HIPAA guidelines, and internal quality standards.

Skills

Analytical skills

Communication skills

Reporting skills

Quality auditing

Independence

MS Excel

Tools

Quality tracking tools

Job description

4-8yrs

Full-Time

Job Description: Prior Authorization – HB QA

Position: Quality Analyst (QA) – Prior Authorization

Process: Hospital Billing (HB) – US Healthcare RCM

Experience: 4–8 years in US Healthcare RCM, including relevant Prior Authorization QA experience

Job Summary

We are looking for an experienced Prior Authorization – HB Quality Analyst to monitor the quality of hospital prior authorization processes, ensure compliance with payer requirements, identify process gaps, and drive continuous improvement in quality and productivity.

Key Responsibilities

• Perform quality audits on Hospital Billing (HB) Prior Authorization transactions.
• Review authorization requests for accuracy, completeness, and compliance with payer guidelines.
• Validate patient demographics, insurance eligibility, medical necessity requirements, CPT/HCPCS codes, diagnosis codes, and authorization details, as applicable.
• Verify authorization status, approved service details, validity dates, units, and payer-specific requirements.
• Identify errors, process deviations, and documentation gaps, and provide timely feedback to associates.
• Conduct root cause analysis (RCA) for recurring errors and implement corrective and preventive actions.
• Prepare and maintain quality reports, audit findings, and performance dashboards.
• Conduct calibration sessions with Operations and Training teams to ensure consistent quality standards.
• Support process training, refresher sessions, and quality improvement initiatives.
• Monitor quality trends and recommend actions to improve accuracy, compliance, and turnaround time.
• Ensure adherence to client requirements, SOPs, HIPAA guidelines, and internal quality standards.

Required Skills and Qualifications

• Strong experience in US Healthcare RCM, specifically Hospital Billing (HB) Prior Authorization.
• Hands-on experience in quality auditing and feedback delivery.
• Good understanding of US insurance plans, payer guidelines, authorization workflows, and medical necessity requirements.
• Knowledge of CPT/HCPCS codes, ICD-10 diagnosis codes, and authorization‑related documentation.
• Experience with quality metrics, sampling methodologies, RCA, and corrective action plans.
• Strong analytical, communication, and reporting skills.
• Proficiency in MS Excel and quality tracking tools.
• Ability to work independently and meet quality and productivity targets.