JOB TITLE: Prior Authorization Specialist
JOB SUMMARY:
The Prior Authorization Specialist is responsible for obtaining, tracking, and documenting insurance authorizations for medical services, procedures, medications, and treatments. This position works closely with providers, clinical staff, patients, insurance companies, billing, and revenue cycle teams to ensure timely approvals, minimize delays in patient care, prevent authorization-related denials, and support positive patient and financial outcomes. This role is also responsible for proactively verifying payer-specific requirements, monitoring authorization expirations, and ensuring authorizations accurately reflect ordered treatment regimens, drug dosages, frequencies, diagnosis codes, treatment dates, and approved services.
REPORTS TO: Director of Patient Financial Services
PRINCIPAL DUTIES
Submit prior authorization requests to insurance companies through payer portals, phone calls, fax, or electronic submission systems.
Review treatment plans and verify payer-specific requirements prior to treatment initiation to ensure compliance with authorization, medical necessity, drug, diagnosis, and site-of-care requirements.
Verify insurance benefits and determine authorization requirements for scheduled services, treatments, procedures, medications, treatment changes, dose modifications, additional cycles, and supportive care services.
Ensure authorizations accurately reflect ordered treatment regimens, drug dosages, frequencies, diagnosis codes, units, treatment dates, and approved services.
Track authorization requests and follow up with insurance carriers to obtain timely determinations.
Monitor authorization expiration dates and proactively obtain extensions or renewals to prevent treatment delays and claim denials.
Document authorization approvals, denials, pending requests, payer communications, approval numbers, effective dates, units, drug details, and related information accurately within the electronic medical record and billing systems.
Coordinate with providers, nursing, and clinical staff to obtain medical records, clinical documentation, treatment details, and supporting information required for authorization requests and medical necessity reviews.
Identify authorization requests requiring clinical review, peer-to-peer discussion, or provider input and escalate timely to the appropriate clinical team member.
Communicate authorization status updates to patients, providers, clinical staff, and other departments as appropriate.
Review denied authorization requests and assist with gathering documentation needed for reconsiderations, appeals, or additional payer review.
Maintain current knowledge of payer-specific authorization requirements, medical necessity guidelines, medical policies, covered services, specialty drug authorization requirements, and site-of-care requirements.
Maintain payer-specific authorization reference materials and communicate updates to impacted departments.
Identify and communicate potential authorization delays that may impact patient care or reimbursement.
Collaborate with Revenue Cycle, Billing, Clinical Operations and other internal departments to identify and resolve authorization-related denial trends and root causes.
Support revenue cycle and billing functions by ensuring required authorizations are obtained, accurate, and documented appropriately prior to services being billed.
Maintain compliance with organizational policies, payer requirements, HIPAA regulations, and applicable state and federal regulations.
Participate in departmental meetings, training programs, and process improvement initiatives.
Perform other duties as assigned.
PERFORMANCE REQUIREMENTS
Strong organizational skills with the ability to manage multiple priorities and deadlines.
Excellent communication and customer service skills.
Ability to work independently while maintaining accuracy and attention to detail.
Strong critical thinking, problem-solving, and root-cause analysis skills.
Ability to interpret insurance policies, payer medical policies, authorization requirements, medical necessity criteria, and specialty drug authorization requirements.
Ability to analyze authorization and denial trends and identify opportunities to prevent recurring authorization-related denials.
Ability to prioritize work based on treatment schedules, authorization turnaround times, patient access needs, and financial impact.
Demonstrated ability to manage high-volume workloads while maintaining accuracy and timeliness.
Working knowledge of medical terminology, healthcare procedures, oncology treatment regimens, infusion services, specialty medications, and insurance processes.
Strong understanding of authorization requirements for infusion, oncology, and supportive care services preferred.
Proficiency with electronic medical records, insurance portals, payer systems, and Microsoft Office applications.
Ability to maintain confidentiality and comply with HIPAA regulations.
Ability to work effectively with patients, providers, clinical staff, billing, revenue cycle, and insurance representatives.
Ability to accurately document and communicate authorization outcomes.
TYPICAL PHYSICAL DEMANDS
Requires full range of motion, including manual dexterity and eye-hand coordination for computer use, data entry, and document handling.
Frequent sitting with occasional standing and walking throughout the workday.
Occasionally lifts and carries items weighing up to 25 pounds.
Requires corrected vision and hearing to a normal range for effective communication and review of documentation.
Ability to work under pressure and meet deadlines in a high-volume environment.
TYPICAL WORKING CONDITIONS
Work is primarily performed in an office environment with extensive computer use.
Frequent interaction with patients, providers, clinical staff, and insurance representatives.
Regular communication regarding authorization approvals, denials, and treatment scheduling needs.
May occasionally encounter frustrated patients or payer representatives related to authorization decisions or delays.
EDUCATION
High school diploma or GED required.
Associate degree in healthcare administration, business, or a related field preferred.
EXPERIENCE
Minimum of two (2) years of experience in a healthcare, medical office, insurance, or revenue cycle environment preferred.
Prior authorization, insurance verification, medical billing, or related healthcare experience preferred.
Experience working with electronic medical records and payer portals preferred.
Knowledge of Oncology treatment, regimens, infusion services, and specialty medications preferred.
Experience obtaining authorizations for chemotherapy, immunotherapy, supportive care drugs, specialty medications, and advanced imaging preferred.
Experience working with Medicare, Medicare Advantage, Medicaid, and commercial payer authorization processes preferred.
Clinical background, coding knowledge, or experience working directly with oncology treatment regimens preferred.
POSITION SUMMARY
The Prior Authorization Specialist plays an important role in supporting patient access to care by ensuring timely and accurate authorization processing, maintaining compliance with payer requirements, preventing authorization-related denials, and supporting efficient revenue cycle operations. This position requires strong attention to detail, proactive follow-up, effective communication with clinical and revenue cycle teams, and the ability to manage payer requirements in a high-volume oncology environment.
