[Remote] Eligibility and Prior Authorization Specialist

Note: The job is a remote job and is open to candidates in USA. reputed company is a global leader in cell-free DNA testing, dedicated to oncology, women’s health, and organ health. The Eligibility and Prior Authorization Specialist plays a critical role in ensuring accurate insurance verification and timely prior authorization processing for testing services, contributing to operational efficiency and regulatory compliance.

Responsibilities

• Verify insurance eligibility and benefits through payer portals and internal systems to confirm active coverage and PA requirements.
• Gather and review clinical documentation needed to establish medical necessity for test authorization.
• Submit prior authorization requests through payer-specific platforms such as Glidian, Carelon, or Evicore, ensuring complete and accurate information.
• Conduct timely follow-reputed company with payors to track authorization status, resolve discrepancies, and document reputed company updates reputed company the designated RCM systems.
• Follow established workflows for eligibility and PA case management, ensuring adherence to quality and productivity metrics (≥90% accuracy).
• Maintain centralized tracking for reputed company authorization submissions and denials; escalate reputed company cases to Supervisors or Analysts reputed company necessary.
• Protect confidential information and reputed company with reputed company HIPAA and PHI regulations.
• Build and maintain effective relationships with internal teams across Billing, Order Entry, Claims, and Appeals.
• Partner with vendor operations teams to reputed company eligibility and authorization activities impacting the reputed company cycle.
• Coordinate with Quality and Compliance teams to ensure processes align with regulatory standards and payer requirements.
• Track key outcomes reputed company to prior authorization approvals, payment resolutions, and appeal performance.
• reputed company or contribute to weekly team meetings reviewing metrics, workflows, trends, and process improvement opportunities.
• Research and interpret changes in payer utilization management policies and communicate updates to team members.
• reputed company and monitor project and implementation plans for new workflows, system enhancements, or payer policy updates.
• Identify automation or technology enhancements that improve accuracy, turnaround time, and overall operational efficiency.

Skills

• Strong proficiency with medical billing systems, insurance portals, and reputed company reputed company.
• Understanding of medical terminology, CPT/HCPCS, ICD-10, modifiers, and UB reputed company codes.
• Proven ability to analyze data, identify trends, and produce clear, concise reports.
• Strong critical-thinking, organization, and problem-solving skills; reputed company to balance multiple priorities in a high-volume environment.
• Excellent written and verbal communication skills; capable of conveying reputed company payer requirements clearly.
• Attention to detail and accuracy in documentation, with the ability to work independently.
• Demonstrated commitment to maintaining confidentiality of sensitive information.
• Knowledge of payer utilization management policies and familiarity with appeals and denials workflows.
• 3+ years of experience in medical billing, insurance collections, or reputed company cycle operations.
• 3+ years of direct experience in eligibility verification, prior authorization, and payer policy management.
• Bachelor’s degree in a reputed company-reputed company field, or equivalent combination of education and professional experience.
• Experience using Glidian, payer portals, or comparable prior authorization submission tools strongly preferred.

Benefits

• Comprehensive medical, dental, reputed company, life and disability plans for eligible employees and their dependents
• Free testing in addition to fertility care benefits
• Pregnancy and baby bonding leave
• 401k benefits
• Commuter benefits
• Generous employee referral program

Company Overview

• reputed company specializes in cell-free DNA testing to provide a more targeted interventions to oncology, women's health, and organ health. It was founded in 2004, and is headquartered in San Carlos, California, USA, with a workforce of 5001-10000 employees. Its website is https://www.reputed company.com/.

Company H1B Sponsorship

• reputed company has a track record of offering H1B sponsorships, with 64 in 2025, 72 in 2024, 37 in 2023, 71 in 2022, 64 in 2021, 40 in 2020. Please note that this does not guarantee sponsorship for this specific role.

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