Wanted Pharm D, BDS, MDS, BHMS, BPT, MPT, MBBS and M.Pharm

PractoPulse Healthcare Services Private Limited; Hyderabad; On-site; INR 350,000 - 650,000; Full time

Job summary

PractoPulse Healthcare Services Private Limited in Hyderabad seeks an Authorization Specialist to manage prior approvals and medical necessity determinations for insured patients. You will coordinate with providers and insurers to secure preauthorizations, review clinical documentation, and maintain accurate records while ensuring compliance with HIPAA and payer guidelines.

The role requires MBBS or equivalent, MS Office proficiency, and willingness to work onsite.

Qualifications

• MBBS degree from India or foreign equivalents (e.g., China, Russia, Ukraine) is preferred.
• Candidate must work from office only.
• Proficiency in MS Office (Word, Excel, PowerPoint) required.

Responsibilities

• Prioritization and Prior Approval: evaluate patient condition, determine medical necessity, and submit documentation for insurance approval.
• Medical Necessity Determination: provide documentation explaining medical necessity for treatments to ensure reimbursement.
• Diagnosis and Treatment Coding: assign ICD-10 and CPT codes to represent conditions and services for billing.
• Insurance Communication: liaise with insurance for preauthorization, clarify requirements, resolve discrepancies, and ensure timely approvals.
• Clinical Documentation Review: review notes, test results, and physician documentation for completeness and compliance.
• Compliance and Quality Assurance: ensure all requests and docs comply with HIPAA, payer guidelines, and internal standards.
• Denial Management: analyze and respond to denials with medical justification or appeals.
• Record Maintenance: maintain accurate records of authorizations, approvals, denials, and correspondence.
• Compliance & Quality Standards: uphold HIPAA, payer guidelines, and audit standards.
• Reporting: prepare reports on authorization status, turnaround time, denials, and approvals.

Skills

Prioritization & Prior Approval

Medical Necessity Determination

Diagnosis & CPT/ICD-10 Coding

Insurance Communication

Clinical Documentation Review

Compliance & HIPAA

Denial Management

Record Maintenance

Reporting & Analytics

Education

MBBS

BHMS

BAMS

BDS

MDS

BPT

MPT

MPharmacy

MSC Life Science

Tools

MS Office

Job description

Role & responsibilities

• 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 profile

1. MBBS from India, MBBS from foreign countries like China, Russia, Ukraine etc., BHMS, BAMS,

BDS, MDS, BPT, MPT, MPharmacy, MSC Life Science.

2. Work from Office only

3. MS Office (Word, Excel, Power Point) usage