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We are looking for an experienced Prior Authorization Specialist with expertise in Orthopedics and Pain Management to support a U.S.-based healthcare practice. The ideal candidate should have hands-on experience obtaining prior authorizations for orthopedic procedures, pain management treatments, imaging services, injections, medications, and surgical procedures. The candidate must be familiar with U.S. insurance guidelines, payer portals, and EMR/EHR systems while ensuring timely approvals and minimizing treatment delays.
Key Responsibilities
Submit and manage prior authorization requests for orthopedic and pain management services.
Process authorizations for procedures, surgeries, injections, imaging (MRI, CT, X-ray), physical therapy, durable medical equipment (DME), and specialty medications.
Verify patient insurance eligibility, benefits, and authorization requirements.
Communicate with insurance companies to obtain approvals, provide clinical documentation, and resolve authorization issues.
Follow up on pending prior authorizations and appeals to ensure timely decisions.
Coordinate with physicians, medical assistants, and clinical staff to gather required medical records and supporting documentation.
Document authorization status, reference numbers, and payer communications accurately in the EMR/EHR.
Stay updated on payer policies, medical necessity guidelines, and insurance requirements.
Escalate urgent or complex authorization cases when necessary.
Maintain productivity and accuracy while meeting turnaround time expectations.
Required Qualifications
Minimum 2+ years of experience in U.S. Healthcare Prior Authorization.
Hands-on experience with Orthopedics and Pain Management prior authorizations.
Strong knowledge of commercial insurance, Medicare, Medicaid, and managed care plans.
Experience with payer portals such as CoverMyMeds, Availity, Carelon, RadMD, Evicore, Cohere, UHC, and other payer websites.
Familiarity with EMR/EHR systems such as Athenahealth, eClinicalWorks (eCW), Epic, Kareo, NextGen, or similar platforms.
Excellent verbal and written English communication skills.
Strong analytical, problem-solving, and multitasking abilities.
Ability to work independently in a fast-paced remote environment.
