Prior Authorization Specialist

Position Summary

The Prior Authorization Specialist is responsible for obtaining timely insurance authorizations for clinic-based services, including infusion therapies (such as chemotherapy and biologics), surgical procedures, and oral specialty medications. This role plays a critical part in ensuring patients receive medically necessary care without delays by coordinating authorization activities across providers, payers, pharmacy, and clinical staff in a fast-paced outpatient clinic environment.

Key Responsibilities

• Obtain prior authorizations for clinic-based services, including:
• Infusion therapies (chemotherapy, immunotherapy, biologics, and supportive medications)
• Surgical procedures and related services
• Oral and specialty medications
• Review provider orders, clinical notes, operative plans, and supporting documentation to ensure completeness and payer compliance
• Submit authorization requests via payer portals, electronic systems, phone, and fax
• Verify insurance benefits, coverage criteria, and payer-specific requirements, including step therapy, site-of-care rules, and clinical guidelines
• Track authorization status and proactively follow up with insurance carriers to secure timely determinations
• Communicate authorization approvals, denials, and pending requirements to providers, nurses, surgery schedulers, pharmacy, and front-desk teams
• Coordinate peer-to-peer reviews and appeal processes with providers and leadership when authorizations are denied or delayed
• Ensure authorizations are obtained prior to scheduled clinic visits, infusion appointments, surgeries, or medication dispensing
• Maintain accurate and up-to-date documentation in the electronic medical record (EMR) and authorization tracking systems
• Collaborate with billing and coding staff to ensure authorized services align with CPT, HCPCS, ICD-10 codes, and payer requirements
• Stay current on payer policies, clinic workflows, and regulatory standards impacting outpatient services
• Maintain compliance with HIPAA, organizational policies, and payer regulations

Required Qualifications

• High school diploma or equivalent (Associate's degree preferred)
• Minimum of 2 years of experience in prior authorization and healthcare revenue cycle.
• Demonstrated experience with medication and procedural authorizations
• Knowledge of commercial insurance, Medicare, Medicaid, and managed care plans
• Proficiency with EMR systems and insurance payer portals
• Strong organizational skills with the ability to manage multiple authorization requests simultaneously
• Excellent written and verbal communication skills

Preferred Qualifications

• Prior experience in a clinic, outpatient specialty practice, or ambulatory surgery setting
• Experience with oncology, infusion services, or surgical scheduling
• Knowledge of oral oncolytics and specialty pharmacy coordination
• Familiarity with CPT, HCPCS, ICD-10 coding and medical necessity guidelines

Skills & Competencies

• High attention to detail and accuracy
• Strong follow-through and time management skills
• Ability to work independently while supporting a multidisciplinary clinic team
• Problem-solving skills with a patient-centered approach
• Comfort working with time-sensitive and high-priority cases

Work Environment

• Specialty practice setting
• Primarily administrative role with frequent collaboration with clinical and scheduling staff
• Fast-paced environment requiring prioritization of urgent authorizations for procedures, infusions, and medications