Prior Authorization RCM Cycle

Responsibilities

• Handle the end-to-end prior authorization process for medical procedures, services, and treatments.
• Verify patient insurance eligibility and benefits before initiating authorization.
• Review insurance policies to determine whether prior authorization is required.
• Submit authorization requests through insurance portals, payer websites, fax, or phone.
• Collect and validate required clinical and patient information for authorization submission.
• Coordinate with providers, clinical teams, and insurance companies for missing documentation.
• Follow up with insurance companies on pending authorization requests.
• Track authorization status and maintain accurate records in the relevant system.
• Communicate authorization approvals, denials, and additional documentation requirements to the appropriate teams.
• Work on authorization denials and re-submissions where applicable.
• Ensure authorizations are obtained within payer-specific timelines to avoid service delays and potential claim denials.
• Maintain accurate documentation of authorization numbers, effective dates, expiration dates, and approved services.
• Identify authorization-related issues that may impact claims processing and reimbursement.
• Meet defined productivity, quality, accuracy, and turnaround-time (TAT) targets.
• Follow HIPAA, payer, client, and company compliance requirements.
• Escalate complex authorization issues to the appropriate team or supervisor.
• Maintain confidentiality of patient and healthcare information.Role &

Preferred candidate profile

• Candidates with 1-4 years of experience in US Healthcare RCM, particularly Prior Authorization, Eligibility, Insurance Verification, or related processes.
• Experience working with US insurance payers and provider offices will be preferred.
• Candidates with knowledge of medical terminology and US healthcare processes are preferred.
• Good communication skills and willingness to meet process targets.