SME -PA/EV

Prior Authorization (PA) – Subject Matter Expert (SME)

At Staffingly, Inc., we are a leading healthcare outsourcing partner dedicated to supporting medical practices, hospitals, and healthcare organizations across the U.S. Our mission is to simplify healthcare operations through reliable and efficient business process solutions — enabling providers to focus on delivering exceptional patient care.

We are looking for an experienced Prior Authorization (PA) Subject Matter Expert (SME) to join our growing healthcare team. The ideal candidate will have a strong background in managing and mentoring PA teams, resolving escalations, and ensuring compliance with payer and client requirements.

Key Responsibilities

• Serve as the subject matter expert for all Prior Authorization processes across multiple specialties (pharmacy, radiology, DME, outpatient, etc.).
• Oversee and guide PA teams to ensure timely and accurate completion of authorizations.
• Handle escalated or complex cases requiring in-depth payer knowledge or multi-step approval processes.
• Review clinical documentation and coordinate with providers to gather required information for submission.
• Communicate with insurance companies via portals, fax, and phone calls to obtain authorizations.
• Track and manage authorizations through their lifecycle, from initiation to approval or denial resolution.
• Conduct training sessions and provide real-time feedback to team members.
• Audit PA cases to identify quality gaps and recommend process improvements.
• Stay current with payer-specific rules, policy updates, and coding requirements.
• Collaborate with QA, billing, and client management teams to optimize turnaround time and reduce denials.
• Ensure compliance with HIPAA and internal security protocols.

Key Requirements

• Minimum 2.5+ years of experience in Prior Authorization (Pharmacy or Medical).
• Strong expertise in payer portals (Availity, NaviNet, Cigna, UHC, Anthem, Medicare/Medicaid portals, etc.).
• In-depth understanding of ICD-10, CPT, and HCPCS codes for authorization validation.
• Hands-on experience with EMRs such as eClinicalWorks, Athenahealth, AdvancedMD, or Kareo.
• Proven ability to handle complex and high-volume authorization workflows independently.
• Excellent English communication skills — written and verbal.
• Analytical mindset with strong problem-solving and leadership abilities.
• Reliable internet connection and quiet remote workspace.

Preferred Qualifications

• Experience leading or mentoring a PA team or working in a Team Lead/SME capacity.
• Exposure to multi-specialty PA processes (Cardiology, Radiology, Orthopedics, Behavioral Health, etc.).
• Knowledge of denial management and appeals process.
• Experience using tools like RingCentral, Zoom, Google Workspace, and VoIP-based systems.