PractoPulse Healthcare is recruiting for the position of Clinical Authorization Specialist in Hyderabad. The role involves prior authorization, medical necessity assessment, clinical documentation review, insurance coordination, denial management, and healthcare compliance.
The position is suitable for candidates with qualifications such as MBBS, BHMS, BAMS, BDS, MDS, BPT, MPT, or Pharm.D.
Job Details
| Particulars | Details |
|---|---|
| Company | PractoPulse Healthcare |
| Job Title | Clinical Authorization Specialist |
| Job ID | 1037 |
| Job Type | Full-time |
| Department | Clinical Authorization |
| Location | Hyderabad |
| Experience | 0–2 years |
| Work Mode | Work from Office |
| Shift | Night Shift |
| Posted By | PHS_Recruiter |
Position: Clinical Authorization Specialist
The selected candidate will review clinical documentation, determine medical necessity, coordinate with insurance companies for prior approvals, and maintain compliance with healthcare documentation and payer requirements.
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Roles and Responsibilities
- Evaluate patient conditions and submit prior authorization requests to insurance companies.
- Assess medical necessity and provide supporting clinical documentation.
- Assign appropriate ICD-10 diagnosis codes and CPT procedure codes.
- Communicate with insurance companies to obtain preauthorization and resolve discrepancies.
- Review clinical notes, test results, and physician documentation.
- Ensure compliance with HIPAA regulations, payer guidelines, and internal quality standards.
- Manage denied authorization requests through additional medical justification or appeals.
- Maintain records of authorization requests, approvals, denials, and correspondence.
- Prepare daily, weekly, and monthly reports covering authorization status, turnaround time (TAT), denials, and approvals.
- Identify process gaps and support quality improvement initiatives.
Eligibility and Qualifications
Candidates with the following qualifications are eligible to apply:
- MBBS (India or foreign countries, including China, Russia, and Ukraine)
- BHMS
- BAMS
- BDS
- MDS
- BPT
- MPT
- Pharm.D
Additional Requirements
- Willingness to work night shifts.
- Willingness to work from the office.
- Knowledge of MS Office applications, including Word, Excel, and PowerPoint.
Required Skills
- Clinical documentation review
- Medical necessity assessment
- Prior authorization and insurance communication
- ICD-10 and CPT coding
- Denial management and appeals
- Healthcare compliance and patient confidentiality
- Reporting and turnaround-time monitoring
- MS Office proficiency
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