Pre-Auth Executive

Responsible for managing prior authorizations and referrals, including verifying insurance eligibility, reviewing clinical data, and ensuring timely approvals. Must demonstrate accuracy (95%+), critical thinking, problem-solving, and the ability to multitask in a fast-paced, team-oriented environment while maintaining compliance with client workflows.

Work Mode: Work from office
Shift Timings: 6pm to 3am (Night Shift)
Location: Mumbai (Vikhroli)

Primary Functions:

Verifies insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt, pt estimation calculation
-Successfully works with payers via electronic/telephonic and/or fax communications. -Responsible for verification and investigation of pre-certification, authorization, and referral requirements for services. -Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits. -Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review. -Communicates with clinical partners, financial counselors(Pt estimation), and others as necessary to facilitate authorization process. -Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals. -Appropriately prioritizes workload to ensure the most urgent cases are handled in a timely manner. Completes accurate documentation in both the Auth/Cert and Referral Shells. -Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements. -Ensures timely and accurate insurance authorizations are in place prior to services being rendered. -Follows departmental policies and procedures when necessary authorization is not obtained prior to service date. -Answers provider, staff(prognocis messages), and patient (email from CM, PFS) questions surrounding insurance authorization requirements. -Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations. -Communicate any insurance changes or trends among team. -Clearly document all communications and contacts with providers and personnel in standardized documentation requirements, including proper format. -Denial management, finding trends/Medical policies benefical for pre-auth process/Identify and report trends and prior authorization issues relating to billing and reimbursement. -Performs other related duties as required or assigned.

(Mandatory Qualifications & Skills):

Bachelor s degree (in any stream).

-Minimum of two years experience in hospital billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMOs and PPOs required.
-Exceptional customer relations skills required -Knowledge of online insurance eligibility systems. -Excellent typing and computer skills. -Familiarity with Medical Terminology/interpretation of clinical documents -Demonstrated ability to efficiently organize work and maintain a high level of accuracy and productivity. -Excellent verbal and written communication skills -Able to work effectively in a team environment -Excel/Google sheet proficiency

What Would Make You Stand Out:

(Preferred/Good-to-Have Skills)

Prior Authorization experience in Drugs and Radiology.

Familiarity with revenue cycle processes.

Accounts Receivable experience.

Ability to work independently while collaborating effectively in a team.

Skills/ Behavioural Skills:

Benefits: