Prior Authorization Specialist

Southwest Womens Oncology/Optimum•Albuquerque, NM

1d•Onsite

About The Position

A patient with a cancer diagnosis should not have to wait for treatment because the paperwork wasn't handled correctly. Prior authorization is one of the most consequential administrative functions in oncology and infusion care. When it works-done completely, submitted correctly, followed up on relentlessly-patients get to their infusion chair, operating room, and medication on time. When it doesn't, care is delayed, revenue is lost, and the clinical team absorbs friction that shouldn't exist. The Prior Authorization Specialist owns that process for clinic-based infusion therapies, surgical procedures, and specialty medications across Southwest Women's Oncology and Optimum Infusion. This is a high-stakes, detail-driven role for someone who takes patient access personally and follows through without being asked. We hire for attitude and aptitude above all else. Credentials matter, but who you are and how you grow matter more.

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.