Oncology Authorization Specialist

POSITION SUMMARY

The Oncology Authorization Specialist is responsible for obtaining, verifying, and maintaining prior authorizations for services across the organisation's oncology service lines, including Medical Oncology/Hematology, Infusion Therapy, Radiation Oncology and Surgical Oncology. This role reviews insurance coverage, payer requirements, physician orders, treatment plans, and supporting clinical documentation to ensure authorization requirements and medical necessity criteria are satisfied prior to the delivery of services. The Oncology Authorization Specialist communicates with insurance payers, utilization management vendors, providers, clinical teams, and Revenue Cycle staff to facilitate timely authorization approvals and prevent treatment delays and authorization-related denials. The position requires comprehensive knowledge of payer authorization requirements, oncology services, medical necessity guidelines, payer portals, and applicable coding terminology. The Specialist monitors authorization status throughout the patient's course of care and ensures approvals accurately reflect the services, dates, units, treatment plans, and other payer requirements associated with the services being provided. Description

POSITION SUMMARY

The Oncology Authorization Specialist is responsible for obtaining, verifying, and maintaining prior authorizations for services across the organisation's oncology service lines, including Medical Oncology/Hematology, Infusion Therapy, Radiation Oncology and Surgical Oncology. This role reviews insurance coverage, payer requirements, physician orders, treatment plans, and supporting clinical documentation to ensure authorization requirements and medical necessity criteria are satisfied prior to the delivery of services. The Oncology Authorization Specialist communicates with insurance payers, utilization management vendors, providers, clinical teams, and Revenue Cycle staff to facilitate timely authorization approvals and prevent treatment delays and authorization-related denials. The position requires comprehensive knowledge of payer authorization requirements, oncology services, medical necessity guidelines, payer portals, and applicable coding terminology. The Specialist monitors authorization status throughout the patient's course of care and ensures approvals accurately reflect the services, dates, units, treatment plans, and other payer requirements associated with the services being provided. Core Essential Responsibilities Obtain and manage prior authorizations for Medical Oncology, Hematology, Radiation Oncology, Surgical Oncology, and related oncology services. Review physician orders, treatment plans, clinical documentation, diagnosis and procedure information, and payer requirements to determine authorization and medical necessity requirements. Submit complete and accurate authorization requests and supporting clinical documentation to payers and utilization management vendors; maintain accurate authorization documentation in the EMR, including submissions, approvals, denials, authorization numbers, approved services and units, and effective date ranges. Support patient financial clearance prior to scheduled services by confirming insurance coverage and benefits, authorization and referral requirements, and applicable patient financial responsibility; communicate outstanding requirements or financial concerns to appropriate team members. Monitor pending authorization requests and proactively follow up with payers and utilization management vendors to prevent delays in treatment, procedures, and other scheduled oncology services. Utilize payer and utilization management portals, including Evolent, eviCore, Optum, Availity, and other payer-specific systems, to submit, track, and manage authorization requests. Validate authorization approvals against ordered and scheduled services to ensure approved procedures, CPT/HCPCS codes, units, frequency, dates of service, and site of care are accurate prior to service delivery. Monitor changes in treatment plans, procedures, units, frequency, dates of service, or site of care that may affect existing authorizations and obtain updated or revised authorizations when required. Collaborate with physicians, advanced practice providers, clinical teams, Insurance Verification, and Revenue Cycle staff to resolve authorization issues and coordinate peer-to-peer reviews, reconsiderations, and appeals when required. Maintain current knowledge of payer authorization policies, medical necessity requirements, coding guidelines, reimbursement requirements, and regulatory changes affecting oncology services. Support other Revenue Cycle functions as needed, participate in payer education and training, and perform additional duties as assigned. Requirements

REQUIRED EDUCATION & EXPERIENCE

High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, or a related field preferred. Minimum of 2-3 years of experience in medical insurance authorizations, preferably within an oncology or specialty healthcare setting. Experience with Medical Oncology/Hematology, Infusion Therapy, Radiation Oncology, and/or Surgical Oncology authorizations strongly preferred. Experience with insurance verification processes, electronic medical records, payer portals, utilization management platforms, and prior authorization procedures for oncology services. Required Certificates, License Or Registration None Required Knowledge, Skills Or Abilities Comprehensive knowledge of insurance authorization processes, payer requirements, referrals, medical necessity requirements, and oncology authorization workflows. Working knowledge of Medical Oncology/Hematology, infusion therapy, Radiation Oncology, Surgical Oncology services. Familiarity with CPT, HCPCS Level II, and ICD-10-CM coding terminology and the relationship between diagnosis, procedure, medication, units, and authorization requirements. Familiarity with payer and utilization management portals, including Evolent, eviCore, Optum, Availity, and other payer-specific systems. Ability to interpret authorization approvals and verify approved services, codes, medications, units, frequency, dates of service, site of care, and other payer limitations. Ability to identify authorization discrepancies and coordinate corrective action before services are rendered. Strong organizational and time-management skills with the ability to prioritize multiple authorization requests based on scheduled treatment and procedure dates. Understanding of HIPAA regulations, strong verbal and written communication skills, and proficiency in electronic medical record (EMR) and practice management systems #J-18808-Ljbffr Cancer Center of South Florida