Pre-Certification Specialist II, Chemo

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 requiredAdditional 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, authoriza...