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Prior Authorization Specialist - Orthopedics & Pain Management
Prior Authorization Specialist – Orthopedics & Pain Management
Location: Kondapur, Hyderabad
Employment Type: Full-Time
Job Summary
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.
Preferred Qualifications
- Experience handling orthopedic surgeries, spinal procedures, pain injections, nerve blocks, epidural steroid injections, radiofrequency ablation (RFA), joint injections, physical therapy, DME, and musculoskeletal imaging authorizations.
- Experience with authorization appeals and peer-to-peer coordination is an added advantage.
