Pre-Auth Executive

Job Description
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:

· Verify patient insurance coverage and eligibility.

· Identify and complete the correct prior authorization form required for each payer.

· Assist in the initiation of new prior authorization/referrals.

· Review clinical data against specified medical criteria for authorization.

· Review incoming orders for completeness to determine if an authorization will be approved.

· Monitor client schedules for upcoming appointments to ensure timely approvals.

· Follow up on pending requests and maintain proper tracking until closure.

· Utilize payer portals to submit and monitor authorizations.

· Coordinate Peer-to-Peer reviews when necessary.

· Communicate with insurance providers daily to obtain and confirm authorizations.

· Ensure compliance with client workflows, payer protocols, and company standards.

· Meet departmental production standards and accuracy benchmarks consistently.

· Identify issues and escalate to management when required.

· Support the team approach by assisting colleagues and sharing best practices.

· Train new staff members when assigned.

· Perform additional duties as assigned.

(Mandatory Qualifications & Skills):

Bachelor’s degree (in any stream).

· At least 6 months to 1 year of relevant experience in Pre-authorization, Verification, or Accounts Receivable (AR).

· Strong attention to detail with the ability to work in a fast-paced environment.

· Proficiency in multitasking and meeting accuracy standards (95%+).

· Effective written and verbal communication skills.

· Knowledge of CPT Codes and ICD-10.

· Knowledge of clinical documentation required for authorizations/referrals.

· Awareness of retro-authorization timelines.

· Understanding of differences between referrals and authorizations.

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
...and more!