Prior Authorization RCM Agent

Position Summary: 

The Prior Authorization RCM Agent is responsible for obtaining timely insurance authorizations for medical procedures, diagnostics, and treatments to prevent claim denials and ensure reimbursement. The role involves coordination with payers and provider teams while adhering to payer guidelines and compliance requirements.

Key Responsibilities

• Submit and track prior authorization requests with commercial, Medicare, and Medicaid payers
• Review clinical documentation and medical necessity prior to submission
• Follow up with payers via portals, phone, and electronic systems to meet TATs
• Communicate with providers to obtain missing or additional documentation
• Maintain accurate authorization records and ensure HIPAA compliance

Required Experience & Skills

• 3+ months of experience in Prior Authorization / Utilization Management (U.S. healthcare)
• Knowledge of payer authorization requirements and medical necessity guidelines
• Experience with EMR/EHR, PM systems, and payer portals
• Strong attention to detail and communication skills

Key KPIs

• Authorization approval rate
• Turnaround time (TAT) adherence
• First-pass accuracy

Authorization-related denial reduction

Benefits:

Benefits include medical insurance, paid leave and holidays, and a 401K