Pre-Auth Executive

Business Unit:

Resolv was formed in 2022, bringing together a suite of industry-leading healthcare revenue cycle leaders with over 30 years of industry expertise, including Ultimate Billing, First Pacific Corporation, Innovative Healthcare Systems, and Innovative Medical Management. Our DNA is rooted in revenue cycle solutions. As we continue to expand, we remain dedicated to partnering with RCM companies that offer diverse solutions and address today's most pressing healthcare reimbursement and revenue cycle operations complexities. Together, we improve financial performance and patient experience, helping to build sustainable healthcare businesses.

Job Summary:

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, HMO's and PPO's 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:

• Problem-Solver: Identifies and resolves healthcare billing discrepancies.
• Organized: Manages high volumes of medical remittances efficiently.
• Clear Communicator: Effectively discusses payment issues with healthcare teams.
• Analytical: Understands healthcare financial data and denial patterns.

Benefits:

• Annual Public Holidays as applicable
• 30 days total leave per calendar year
• Mediclaim policy
• Lifestyle Rewards Program
• Group Term Life Insurance
• Gratuity
• more