Pre-Certification Specialist II, Chemo

DeKalb Health; Little Rock (AR); On-site; USD 42,000 - 66,000; Full time

Job summary

DeKalb Health in Little Rock, AR seeks a Pre-Certification Specialist II, Chemo to obtain and manage prior authorizations for chemotherapy, immunotherapy, and other oncology services. You will verify insurance coverage, review payer requirements, and coordinate documentation to support timely treatment.

You will collaborate with physicians, clinical staff, and payers to resolve authorization issues, track requests, and assist with denials and appeals while maintaining patient confidentiality.

Qualifications

• Minimum of three years of direct experience obtaining and managing prior authorizations for medical services, medications, procedures, or specialty services.
• Oncology, chemotherapy, immunotherapy, or other specialty drug authorization experience strongly preferred.
• Experience working within payer portals such as UHC, BCBS, commercial insurance, Medicare, Medicaid, and/or other third-party payers.
• Working knowledge of ICD-10-CM, CPT, and HCPCS coding and the ability to use coding information to support authorization and coverage research.

Responsibilities

• Verify and maintain accurate patient demographic, insurance, eligibility, benefit, and authorization information.
• Review chemotherapy and oncology-related orders and supporting documentation to identify payer-specific authorization requirements.
• Obtain, prepare, submit, and manage prior authorizations for chemotherapy, immunotherapy, specialty medications, and other oncology-related services.
• Research and apply payer policies, coverage guidelines, and established authorization criteria to ensure required documentation is submitted.
• Coordinate with physicians, clinical staff, pharmacy, and other departments to obtain required clinical documentation and resolve authorization-related issues.
• Monitor authorization requests, follow up with payers, and document authorization status, determinations, and communications to prevent treatment delays.
• Assist with authorization denials, reconsiderations, and appeals by gathering required information and coordinating appropriate follow-up.
• Manage assigned work queues and reports to ensure authorization requests are processed accurately and within established timeframes.
• Communicate authorization requirements, determinations, delays, and potential barriers to appropriate clinical and operational staff.
• Maintain patient confidentiality, comply with organizational policies and applicable regulations, and perform other duties as assigned.

Skills

Prior authorization

Oncology experience

Payer portals

ICD-10-CM CPT coding

Communication

Education

High school diploma

Healthcare administration coursework

Revenue cycle certification (preferred)

Tools

UHC portal

BCBS portal

Medicare portal

Job description

• Location 10411 West Markham Street,Cone Building 2,Little Rock, AR, 72205,United States
• Job Category Revenue Cycle
• Employee Type Non Exempt Full Time

Contact information

• Name Tia L Furlow
• Phone [phone]
• Email [e-mail]

Description

JOB SUMMARY:

The Pre-Certification Specialist II, Chemo is responsible for obtaining and managing prior authorizations for chemotherapy, immunotherapy, specialty medications, and other oncology-related services. The position verifies insurance coverage, reviews payer requirements, and coordinates required documentation to support timely treatment. This role independently manages complex and time-sensitive authorization cases, follows up with payers, and assists with denials and appeals. The Specialist collaborates with clinical and operational teams to resolve authorization issues and minimize delays in patient care.

SPECIFIC JOB DUTIES AND RESPONSIBILITES:

• Verify and maintain accurate patient demographic, insurance, eligibility, benefit, and authorization information.
• Review chemotherapy and oncology-related orders and supporting documentation to identify payer-specific authorization requirements.
• Obtain, prepare, submit, and manage prior authorizations for chemotherapy, immunotherapy, specialty medications, and other oncology-related services.
• Research and apply payer policies, coverage guidelines, and established authorization criteria to ensure required documentation is submitted.
• Coordinate with physicians, clinical staff, pharmacy, and other departments to obtain required clinical documentation and resolve authorization-related issues.
• Monitor authorization requests, follow up with payers, and document authorization status, determinations, and communications to prevent treatment delays.
• Assist with authorization denials, reconsiderations, and appeals by gathering required information and coordinating appropriate follow-up.
• Manage assigned work queues and reports to ensure authorization requests are processed accurately and within established timeframes.
• Communicate authorization requirements, determinations, delays, and potential barriers to appropriate clinical and operational staff.
• Maintain patient confidentiality, comply with organizational policies and applicable regulations, and perform other duties as assigned.

EDUCATION, CERTIFICATION, LICENSURE, REGISTRATION:

• High school graduate or GED required
• Additional education, certification, or coursework in healthcare administration, medical billing, health information management, or a related field is preferred.
• Industry certification related to healthcare revenue cycle, medical billing, or insurance authorization is preferred but not required

EXPERIENCE, KNOWLEDGE, SKILLS and ABILITIES:

• Minimum of three years of direct experience obtaining and managing prior authorizations for medical services, medications, procedures, or specialty services required.
• Oncology, chemotherapy, immunotherapy, specialty medication, or other specialty drug authorization experience strongly preferred.
• Experience working within payer portals such as UHC, BCBS, commercial insurance, Medicare, Medicaid, managed care organizations, and/or other third-party payers.
• Working knowledge of insurance eligibility, benefits, authorization requirements, claims processes, and coverage limitations.
• Working knowledge of ICD-10-CM, CPT, and HCPCS coding and the ability to use coding information to support authorization and coverage research

REASONING ABILITY:

• Abilityto interpret and apply written policies, payer guidelines, authorization requirements, and organizational procedures.
• Ability to analyze information from multiple sources and determine appropriate administrative next steps.
• Ability to identify missing or conflicting information and obtain clarification from appropriate resources.
• Ability to prioritize work based on treatment schedules, authorization deadlines, payer turnaround times, and patient needs.
• Ability to solve practical problems independently and escal…

INTERPERSONAL SKILLS:

• Must interact and communicate both verbally and in written form.
• Must interact and exchange information regarding patients with physicians and other departmental personnel, and outside agencies frequently, while respecting the confidentiality of patient information.
• Demonstrates the ability to collaborate across clinical and operational departments to resolve authorization barriers.
• Maintains composure and professionalism when managing urgent, complex, or time-sensitive authorization issues.
• Demonstrates accountability for assigned work and follows through on outstanding authorization issues

PHYSICAL DEMANDS:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• Specific vision abilities required by this job include close vision and the ability to adjust focus.

WORK ENVIRONMENT:

The work environment described here are representative of those an employee encounters while performing the essential functions of this job.This position involves potential exposure to infectious diseases. Colleagues are offered appropriate vaccinations and safety training.

COMMENTS:

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of the job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.