EVBV / Prior Auth QE

About the Company

Responsibilities

• EVBV (Eligibility Verification & Benefits Validation)

• Act as a subject matter expert for EVBV workflows and payer benefit structures
• Validate member eligibility, coverage status, plan details, copays, deductibles, coinsurance, and benefit limitations
• Ensure correctness of real-time, batch, and EDI 270/271 eligibility transactions
• Review and validate payer-specific rules and mappings
• Identify gaps in requirements and proactively raise quality risks
• Ensure data integrity across downstream systems consuming EVBV results

• Prior Authorization

• Serve as a quality gatekeeper for prior authorization workflows
• Validate authorization rules based on CPT/HCPCS, ICD-10, payer policies, and medical necessity
• Ensure accurate handling of authorization life cycle: submission, pend, approval, denial, partial approval
• Validate EDI 278 transactions and payer portal integrations
• Ensure compliance with TAT, SLA, and regulatory requirements
• Perform root cause analysis for authorization failures and quality issues

Qualifications

• 3+ years of experience in healthcare quality roles
• Strong domain expertise in EVBV and Prior Authorization
• Deep understanding of EDI transactions: 270/271, 278
• Knowledge of payer benefits, authorization policies, and regulatory requirements
• Experience validating API, batch, and EDI integrations
• Strong defect analysis, documentation, and communication skills

Required Skills

• Experience in revenue cycle management (RCM)
• Claims or downstream adjudication knowledge
• Prior role as SME / Quality Lead / Quality Analyst

Pay range

Contact : +91 95272 49946 / +91 72197 17605