Authorization Specialist | Oncology

UPMC•Moon Township, PA

2d•Onsite

About The Position

UPMC Hillman Cancer Center is seeking an Authorization Specialist to support patient access to oncology care. The role is based in the Moon Township office and supports the medical oncology network, including Butler, Beaver, Cranberry, McCandless, Pittsburgh (St. Margaret), and Natrona Heights. Occasional travel to these locations may be required based on operational needs. This is a full-time position with regular Monday-through-Friday hours and no evenings, holidays, or weekends. The Authorization Specialist reviews medical records and coordinates prior authorizations, notifications, edits, denials, and related revenue functions. The position applies payer criteria and relevant laws to authorization requests, ensures accurate coding, and submits required patient and clinical information to payors. The specialist also resolves basic retrospective authorization edits and works with internal and external contacts to support timely care, process compliance, and customer satisfaction.

Requirements

High school diploma or equivalent and two years of work experience in a medical environment, such as a hospital, doctor's office, or ambulatory clinic; alternatively, an associate's degree and one year of experience in a medical environment.
Completion of a medical terminology course or equivalent.
Knowledge and interpretation of medical terminology, ICD-9, and CPT codes.
Proficiency in Microsoft Office applications.
Excellent communication and interpersonal skills.
Ability to analyze data and use independent judgment.
Act 34 clearance.

Nice To Haves

Bachelor's degree.
Understanding of authorization processes, insurance guidelines, third-party payors, and reimbursement practices.
Experience using a web-based computerized system.

Responsibilities

Review and interpret medical record documentation for patient history, diagnosis, and previous treatment plans to pre-authorize procedures determined by insurance plans.
Use payor-specific approved criteria or state laws and regulations to assess medical necessity or clinical appropriateness for inpatient admissions, outpatient facility and office services, durable medical equipment, and drugs.
Ensure accurate coding of diagnoses, procedures, and services using ICD-9-CM, CPT, and HCPCS Level II.
Provide referral, pre-notification, and authorization services in a timely manner to avoid treatment delays and reduce administrative work for providers.
Submit pertinent demographic and supporting clinical data to payors to request approval for services.
Maintain compliance with departmental quality standards and productivity measures.
Collaborate with Physician Services, the Hospital Division, other UPMC contacts, and payors to improve customer satisfaction and process compliance and to support seamless coordination of work.
Use UPMC system and insurance payor or contracted-provider websites to perform prior authorization, edit, and denial services.
Use authorization resources and applicable reference materials to obtain accurate prior authorization.
Resolve basic retrospective authorization edits to support timely claim filing and eliminate payor rejections or denials.
Manage denials and oversee revenue functions.