Job Description: Prior Authorization – HB QA
Position: Quality Analyst (QA) – Prior Authorization
Process: Hospital Billing (HB) – US Healthcare RCM
Experience: 4–8 years in US Healthcare RCM, including relevant Prior Authorization QA experience
Job Summary
We are looking for an experienced Prior Authorization – HB Quality Analyst to monitor the quality of hospital prior authorization processes, ensure compliance with payer requirements, identify process gaps, and drive continuous improvement in quality and productivity.
Key Responsibilities
- Perform quality audits on Hospital Billing (HB) Prior Authorization transactions.
- Review authorization requests for accuracy, completeness, and compliance with payer guidelines.
- Validate patient demographics, insurance eligibility, medical necessity requirements, CPT/HCPCS codes, diagnosis codes, and authorization details, as applicable.
- Verify authorization status, approved service details, validity dates, units, and payer-specific requirements.
- Identify errors, process deviations, and documentation gaps, and provide timely feedback to associates.
- Conduct root cause analysis (RCA) for recurring errors and implement corrective and preventive actions.
- Prepare and maintain quality reports, audit findings, and performance dashboards.
- Conduct calibration sessions with Operations and Training teams to ensure consistent quality standards.
- Support process training, refresher sessions, and quality improvement initiatives.
- Monitor quality trends and recommend actions to improve accuracy, compliance, and turnaround time.
- Ensure adherence to client requirements, SOPs, HIPAA guidelines, and internal quality standards.
Required Skills and Qualifications
- Strong experience in US Healthcare RCM, specifically Hospital Billing (HB) Prior Authorization.
- Hands-on experience in quality auditing and feedback delivery.
- Good understanding of US insurance plans, payer guidelines, authorization workflows, and medical necessity requirements.
- Knowledge of CPT/HCPCS codes, ICD-10 diagnosis codes, and authorization-related documentation.
- Experience with quality metrics, sampling methodologies, RCA, and corrective action plans.
- Strong analytical, communication, and reporting skills.
- Proficiency in MS Excel and quality tracking tools.
- Ability to work independently and meet quality and productivity targets.
