Clinical Insurance Authorization Specialist

US Oncology Network-wide Career Opportunities; Antioch (CA); On-site; USD 36,000 - 45,000; Full time

Job summary

US Oncology Network-wide Career Opportunities is seeking an Authorization Specialist to manage referral and authorization workflows with accuracy across payer guidelines. You will review MD orders, determine CPT/HCPCS codes, and communicate with sites to obtain necessary documentation and approvals.

The role requires familiarity with EMR systems, strong attention to detail, and the ability to escalate when denials occur, including peer-to-peer requests or written appeals.

Qualifications

• High school diploma or equivalent.
• Associate degree in Business Admin/related field preferred.
• Certificate Medical Billing or Insurance preferred.

Responsibilities

• Perform timely review of assigned WQs to ascertain next steps; prioritizing requests based on due date, stat, urgent, etc.
• Review patient chart for MD orders to determine services/CPTs/HCPCs and reasons for requests.
• Review insurance guidelines. If services requested meet medical necessity, gather data to be prepared for phone call, on-line and/or fax to insurance.
• If services do not meet payer guidelines, reach out to RCAUTHSUP and/or ordering provider for next steps.
• If request is denied by insurance, request for peer to peer and/or submit written appeal.
• Enter authorized services into system and all notes pertaining to phone calls.
• Provide communication for sites/providers via email, phone and/or in-basket.
• Maintain in box and fax folder; import medical guidelines via E-scan into EPIC.
• Assist in managing in-basket messages; ensuring all have been appropriately responded to within 48 hrs.
• Assist in managing WQ; ensuring WQ is meeting goal, all WQ notes are updated and any delayed referrals reviewed and identifying trends
• Maintain a 95% or greater audit and productivity score.
• Be able to navigate and trouble shoot authorization-related issues/denials: IE non-contracted facility chosen, non-preferred drug etc.

Education

High school diploma or equivalent

Associate degree in Business Admin/related field

Certificate Medical Billing or Insurance

Tools

EMR

Job description

US Oncology Network-wide Career Opportunities is seeking an Authorization Specialist to manage referral and authorization workflows with accuracy across payer guidelines. You will review MD orders, determine CPT/HCPCS codes, and communicate with sites to obtain necessary documentation and approvals.

The role requires familiarity with EMR systems, strong attention to detail, and the ability to escalate when denials occur, including peer-to-peer requests or written appeals.