Job Description

Job Summary

The Prior Authorization Quality Assurance (QA) Specialist is responsible for auditing and evaluating prior authorization requests, documentation, and team performance to ensure accuracy, compliance, and adherence to client, payer, and regulatory requirements. The QA Specialist identifies trends, provides feedback, supports process improvements, and helps maintain high-quality standards within the Prior Authorization team.

Key Responsibilities

• Conduct quality audits of prior authorization requests and related documentation.
• Review submitted authorizations for accuracy, completeness, and compliance with payer guidelines.
• Monitor team performance and evaluate adherence to established workflows and standard operating procedures (SOPs).
• Identify errors, trends, and process gaps that may impact authorization approval rates or turnaround times.
• Provide detailed feedback and coaching recommendations to Prior Authorization Specialists and Team Leads.
• Perform calibration sessions to ensure consistency and accuracy in quality scoring.
• Track and report quality metrics, audit findings, and recurring issues.
• Assist in developing corrective action plans to address quality concerns.
• Collaborate with Operations, Training, and Leadership teams to improve service quality and operational efficiency.
• Stay updated on payer requirements, authorization processes, and industry best practices.
• Ensure compliance with HIPAA, client requirements, and healthcare regulations.
• Support training initiatives by identifying knowledge gaps and recommending learning opportunities.

Qualifications

• At least 3 years of hands-on Prior Authorization experience, including commercial, Medicare, Medicaid, managed care, and specialty authorizations.
• Minimum 2 years of Quality Assurance (QA) experience within a Prior Authorization, Revenue Cycle Management (RCM), Medical Billing, or Healthcare BPO environment.
• Strong knowledge of payer guidelines, medical necessity requirements, and authorization workflows.
• Experience auditing prior authorization cases for accuracy, completeness, and compliance.
• Familiarity with CPT, ICD-10, HCPCS codes, and medical terminology.
• Experience using EMR/EHR systems, payer portals, and healthcare software.
• Strong analytical, coaching, and performance management skills.
• Excellent communication and reporting skills.
• Proficient in Microsoft Excel and quality reporting tools.

Ideal Candidate

• 3+ years of end-to-end Prior Authorization experience covering all authorization types.
• 2+ years of Quality Assurance experience auditing Prior Authorization specialists and providing coaching and feedback.
• Proven ability to identify trends, improve quality scores, reduce authorization errors, and ensure compliance with payer requirements and client expectations.