Prior Authorization Specialist

Serv Recruitment Agency•Albuquerque, NM

About The Position

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.

Requirements

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
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

Nice To Haves

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

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