Pre-Certification/ Authorization Manager

Pre-Certification/Authorization Manager

Carolina Oncology Specialists is seeking an experienced and strategic Pre-Certification / Authorization Manager to lead and oversee all prior authorization functions across the organization. This role is responsible for ensuring timely and accurate authorization of oncology services, optimizing approval rates, reducing denials, and maintaining compliance with payer and regulatory requirements. The Manager will supervise authorization staff, collaborate with clinical and revenue cycle leadership, and drive process improvements to support high-quality, patient-centered care and financial performance.

Key Responsibilities

• Lead and manage the daily operations of the pre-certification/authorization team
• Oversee the timely submission and follow-up of prior authorizations for oncology services, including chemotherapy, infusions, radiation therapy, imaging, and specialty medications
• Establish and monitor team productivity, quality, and turnaround time metrics
• Ensure compliance with payer guidelines, CMS regulations, and organizational policies
• Develop and implement standard workflows, policies, and best practices for authorization processes
• Monitor authorization trends, denials, and payer behaviors; develop action plans to improve approval rates
• Collaborate with physicians, nursing, scheduling, coding, and billing teams to ensure seamless coordination of patient care and reimbursement
• Oversee denial management processes, including appeals and peer-to-peer review coordination
• Serve as escalation point for complex authorization cases and payer issues
• Provide coaching, training, and performance management for authorization staff
• Participate in audits and compliance reviews to ensure accuracy and regulatory adherence
• Maintain up-to-date knowledge of oncology treatment protocols, payer policy changes, and industry best practices
• Identify and implement opportunities for automation, efficiency, and process improvement
• Support budgeting, staffing, and resource planning for the authorization function

Minimum Qualifications

Education & Certification

• High school diploma or equivalent required
• Bachelor's degree in healthcare administration, business, or related field preferred
• Certification in healthcare access or revenue cycle (e.g., CPAR, CHAA, CRCR) preferred

Experience

• Minimum of 5 years of experience in prior authorizations, insurance verification, or revenue cycle operations
• Minimum of 2 years of leadership or supervisory experience
• Oncology, infusion, or specialty practice experience strongly preferred
• Experience with EMR/EHR systems and payer portals required

Required Skills

• Advanced knowledge of Medicare, Medicaid, and commercial payer authorization requirements
• Strong understanding of oncology services and treatment workflows
• Familiarity with CPT, ICD-10, and HCPCS coding concepts
• Demonstrated leadership, team management, and coaching skills
• Strong analytical and problem-solving abilities
• Excellent communication and interpersonal skills
• Ability to manage multiple priorities in a fast-paced, deadline-driven environment
• Strong organizational skills and attention to detail

Compliance & Legal Statements

Equal Employment Opportunity (EEO)

Carolina Oncology Specialists is an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and prohibit discrimination or harassment based on race, color, religion, sex, gender identity, sexual orientation, national origin, age, disability, genetic information, veteran status, or any other protected status under applicable law.

Americans with Disabilities Act (ADA)

Carolina Oncology Specialists is committed to providing reasonable accommodations for qualified individuals with disabilities. If you require accommodation during the application or employment process, please notify Human Resources.

Background Check & Eligibility

Employment is contingent upon successful completion of a background check and verification of credentials, as permitted by law. Candidates must be authorized to work in the United States without sponsorship.

HIPAA & Confidentiality

This position requires strict adherence to HIPAA regulations and the protection of patient health information (PHI).

At-Will Employment Disclaimer

Employment with Carolina Oncology Specialists is at-will, meaning either the employee or employer may terminate the employment relationship at any time, with or without cause or notice, in accordance with applicable laws.

Job Description Disclaimer

This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications. Duties may be adjusted based on organizational needs.