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.