Oncology - Prior Authorization Specialist (Immediate Joiners)

Responsibilities

• Manage Prior Authorization Process: Oversee the entire prior authorization process for oncology treatments, procedures, and medications, ensuring timely and efficient approvals
• Review Requests: Evaluate prior authorization requests to confirm they meet medical necessity criteria and payer guidelines
• Collaborate with Care Teams: Work closely with oncologists, nursing staff, and billing teams to gather necessary clinical documentation and ensure it is submitted accurately and promptly
• Insurance Coordination: Coordinate with insurance companies to resolve coverage issues, denials, and appeals, ensuring that patients receive the care they need without unnecessary delays
• Record Keeping: Maintain accurate records of all prior authorization requests, including approvals, denials, and appeals, ensuring documentation is compliant and well-organized
• Proactive Problem Resolution: Identify and address barriers to timely approvals, proactively addressing payer-specific requirements and facilitating smoother workflows
• Policy & Guideline Updates: Stay informed on insurance policy changes, payer guidelines, and new oncology treatments to ensure compliance and accurate processing of requests
• Provide Feedback & Insights: Support oncology care teams by offering feedback to improve the prior authorization workflow and streamline operational efficiency
• Utilize Technology: Use electronic medical records (EMR) systems (e.g., OncoEMR) and prior authorization platforms to manage and streamline processes
• Compliance: Ensure all communications and documentation comply with HIPAA and other relevant regulatory standards

Qualifications

• Experience: Minimum of 1 years of experience managing medical prior authorizations, specifically within oncology
• Preferred Experience: Experience working in a cancer center or with oncology clients is highly preferred
• Knowledge: In-depth understanding of oncology treatments, procedures, and insurance requirements for medical prior authorizations
• Insurance & Reimbursement: Strong understanding of insurance policies, reimbursement processes, and medical necessity criteria for oncology care
• Technical Proficiency: Proficient in EMR systems (e.g., OncoEMR or similar platforms) and multiple payer portals, plans, and prior authorization tools
• Communication Skills: Excellent communication and interpersonal skills, with the ability to effectively liaise between healthcare teams, patients, and insurance payers
• Detail-Oriented: Ability to maintain accurate and organized documentation in a fast-paced environment
• Collaboration & Independence: Ability to work independently and collaboratively with care teams in a dynamic oncology care setting
• Compliance Knowledge: Strong knowledge of HIPAA compliance and other regulatory standards
• Preferred Certifications: Certification in Medical Coding, Healthcare Administration, or a related field is a plus