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Job Description
A Prior Authorization (PA) & EVBV (Eligibility Verification & Benefits Validation) QA Job involves auditing healthcare revenue cycle processes (like EVBV via EDI 270/271 & PA via EDI 278/portals) to ensure accuracy, compliance with SLAs, payer rules (CPT/ICD codes), and data integrity, focusing on quality control, root cause analysis for denials/failures, and improving workflow efficiency for billing and patient care. Key tasks include reviewing patient data, verifying insurance, submitting requests, following up on statuses (approvals/denials), and identifying process gaps for training and improvement. 
Core Responsibilities
  • Quality Auditing: Reviewing PA/EVBV processes for accuracy, compliance, and adherence to timelines (TAT/SLA).
  • Eligibility & Benefits: Ensuring correct validation of patient insurance (270/271), coverage, co-pays, and benefits.
  • Prior Authorization Workflow: Gatekeeping the submission, tracking, approval, denial, and appeal stages, often using EDI 278 or payer portals.
  • Data & Integration: Validating data integrity across systems and ensuring accuracy in EDI/API transactions.
  • Issue Resolution: Performing root cause analysis for denials, discrepancies, and quality issues, and working on appeals.
  • Reporting & Improvement: Creating quality reports, providing feedback to operations/training, and supporting process enhancements. 
Key Skills & Experience
  • Domain Expertise: Strong knowledge of Healthcare Revenue Cycle (RCM), EVBV, Prior Authorization, Medical Billing.
  • Technical: Familiarity with EDI transactions (270/271, 278), payer portals, and RCM software.
  • Analytical: Strong defect analysis, problem-solving, and critical thinking.
  • Communication: Excellent verbal/written skills for interacting with providers, payers, and internal teams.
  • Compliance: Understanding of HIPAA and regulatory requirements. 

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