Pre-Certification Specialist

Medix; Knoxville (TN); On-site; USD 29,000 - 34,000; Full time

Benefits offered by this job

Equipment provided on-site

Job summary

Medix in Knoxville, TN seeks an experienced Prior Authorization Specialist to join our Centralized Business Office (CBO) team on-site. You will secure timely prior authorizations for complex specialty medications, chemotherapy, and infusion regimens, ensuring patients receive needed treatments without delay.

The ideal candidate has hands-on experience with payor portals, supportive documentation for medical necessity, and the ability to navigate barriers like peer-to-peer requirements.

Qualifications

• 2+ years of direct healthcare insurance verification and prior authorization experience.

Responsibilities

• Initiate, track, and secure timely prior authorizations for complex specialty medications, chemotherapy, and infusion regimens.
• Submit clinical documentation to payors to justify medical necessity.
• Navigate major payor portals (BlueCross, Medicare/Medicare Advantage, Humana) using Availity and CoverMyMeds.
• Manage appeals and peer-to-peer workflows to navigate payor white-bagging mandates and protect buy-and-bill operations.
• Serve as primary liaison between the CBO, attending physicians, and clinic staff regarding payor restrictions and authorization status updates.

Skills

Prior authorization experience

Healthcare insurance verification

Payor portal navigation

Attention to detail

Communication skills

Education

Certified Medical Assistant (CMA)

Licensed Practical Nurse (LPN)

Healthcare Financial Counselor

Tools

Availity

CoverMyMeds

Job description

Salary: USD21 - USD25 per hour

Job Title: Prior Authorization Specialist – Specialty Medications & Infusion

Location: Knoxville, TN (100% On-site)

Pay Rate: $21.00 – $25.00/hour (Based on experience)

Schedule: Full-Time, Monday – Friday | Choice of shift (7:30 AM–4:00 PM, 8:00 AM–4:30 PM, or 8:30 AM–5:00 PM)

Position Type: Contract-to-Hire

Position Overview

We are seeking an experienced Prior Authorization Specialist with a strong background in pharmaceutical and specialty drug authorizations to join a dedicated Centralized Business Office (CBO) team in Knoxville. In this high-impact role, you will be directly responsible for securing timely coverage for complex medical specialty drugs, chemotherapy, and infusion regimens—ensuring patients receive critical treatments without delay.

The ideal candidate brings deep expertise in navigating payor portals, reviewing clinical documentation for medical necessity, and overcoming payor barriers such as white-bagging mandates and peer-to-peer requirements.

Key Responsibilities

Specialty Drug Authorizations: Initiate, track, and secure timely prior authorizations for complex specialty medications, chemotherapy, and infusion regimens.

Clinical Submission & Medical Necessity: Submit comprehensive clinical documentation (physician notes, lab results, diagnosis codes, regimen details) to payors to justify treatment necessity.

Payor Portal & Workflows: Navigate major regional payor portals and phone lines (BlueCross ~30%, Medicare/Medicare Advantage ~30%, Humana, etc.) using platforms like Availity and CoverMyMeds.

Appeals & White-Bagging Navigation: Manage appeals and peer-to-peer workflows to navigate payor white-bagging mandates and protect in-house buy-and-bill operations.

Interdepartmental Liaison: Serve as the primary contact between the CBO, attending physicians, and clinic staff regarding payor restrictions and authorization status updates.

Required Qualifications

Experience: Minimum 2+ years of direct healthcare insurance verification and prior authorization experience.

Pharmaceutical Focus: Proven experience obtaining prior authorizations specifically for medications and specialty drugs (experience limited to diagnostic imaging or basic procedures will not qualify).

Coding Knowledge: Working knowledge of ICD-10, CPT, and HCPCS coding as it relates to drug medical necessity and payor guidelines.

Portal Proficiency: Strong hands-on experience utilizing major payor portals (Availity, CoverMyMeds, and payor-specific sites).

Core Attributes: High accuracy, urgency, strong problem-solving skills, and proactive communication.

Preferred Qualifications

Direct prior authorization experience in Oncology, Hematology, Chemotherapy, or Specialty Infusion.

Experience operating within Athena IDX.

Background as a Certified Medical Assistant (CMA), Licensed Practical Nurse (LPN), or Healthcare Financial Counselor.

Why Join Us?

Flexible Work Hours: Choose the schedule that best fits your lifestyle (7:30 AM, 8:00 AM, or 8:30 AM start times).

Meaningful Impact: Play a critical role in patient care by ensuring immediate access to lifesaving cancer and specialty treatments.

Career Growth: Direct contract-to-hire pathway into a premier regional healthcare group.

Equipment Provided: Full hardware setup provided on-site.