Prior Authorization Specialist

Southwest Womens Oncology/Optimum•Albuquerque, NM

3d•Onsite

About The Position

The Prior Authorization Specialist is responsible for obtaining timely insurance authorizations for clinic-based services-including infusion therapies such as chemotherapy, immunotherapy, and biologics; surgical procedures; and oral and specialty medications-ensuring patients receive medically necessary care without delays. You will work closely with: Providers and clinical staff on order review, documentation completeness, and peer-to-peer coordination Nurses and infusion schedulers to ensure authorizations are secured prior to every treatment appointment Surgery schedulers on surgical authorization timelines and operative plan documentation Pharmacy on specialty medication authorization and oral oncology coordination Billing and coding staff to ensure authorized services align with CPT, HCPCS, and ICD-10 requirements Your accuracy, urgency, and follow-through directly determine whether patients get to their care on time.

Requirements

High school diploma or equivalent; Associate's degree preferred.
2+ years of prior authorization experience in 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 active authorization requests simultaneously.
Excellent written and verbal communication skills with a patient-centered approach.

Nice To Haves

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

Responsibilities

Obtain prior authorizations for infusion therapies (chemotherapy, immunotherapy, biologics, and supportive medications), surgical procedures, and oral and specialty medications.
Submit authorization requests via payer portals, electronic systems, phone, and fax with complete and payer-compliant documentation.
Track authorization status across all active requests and proactively follow up with insurance carriers to secure timely determinations.
Ensure authorizations are in place prior to scheduled infusion appointments, clinic visits, surgeries, and medication dispensing-without exception.
Review provider orders, clinical notes, operative plans, and supporting documentation to ensure completeness and payer compliance before submission.
Verify insurance benefits, coverage criteria, and payer-specific requirements including step therapy, site-of-care rules, and clinical guidelines.
Maintain accurate, up-to-date documentation in the EMR and authorization tracking systems.
Stay current on payer policies, clinic workflows, and regulatory standards impacting outpatient services.
Communicate authorization approvals, denials, and pending requirements to providers, nurses, surgery schedulers, pharmacy, and front-desk teams in a timely and clear manner.
Coordinate peer-to-peer reviews and appeal processes with providers and leadership when authorizations are denied or delayed.
Collaborate with billing and coding staff to ensure authorized services align with CPT, HCPCS, ICD-10 codes, and payer requirements.
Maintain strict compliance with HIPAA, organizational policies, and payer regulations at all times.