Prior Authorization Specialist
hace 15 días
Albuquerque
Job Description Prior Authorization Specialist Southwest Women's Oncology + Optimum Infusion | Albuquerque, New Mexico Why This Role Matters A patient with a cancer diagnosis should not have to wait for treatment because the paperwork wasn't handled correctly. Prior authorization is one of the most consequential administrative functions in oncology and infusion care. When it works - done completely, submitted correctly, followed up on relentlessly-patients get to their infusion chair, operating room, and medication on time. When it doesn't, care is delayed, revenue is lost, and the clinical team absorbs friction that shouldn't exist. The Prior Authorization Specialist owns that process for clinic-based infusion therapies, surgical procedures, and specialty medications across Southwest Women's Oncology and Optimum Infusion. This is a high-stakes, detail-driven role for someone who takes patient access personally and follows through without being asked. We hire for attitude and aptitude above all else. Credentials matter, but who you are and how you grow matter more. Who We Are Southwest Women's Oncology (SWWO) is New Mexico's leading gynecologic oncology practice, delivering advanced cancer care with skill, courage, and compassion. Optimum Human and Optimum Infusion extend that mission into performance medicine, infusion services, longevity, recovery, hormone optimization, medical weight loss, peptide therapies, hyperbaric medicine, aesthetics, and human performance. Together, we operate as a single integrated platform committed to one mission: To deliver new possibilities in medical care, human performance, and health by uniting passion, knowledge, and precision into something greater than the sum of its parts. The Opportunity The Prior Authorization Specialist is responsible for obtaining timely insurance authorizations for clinic-based services-including infusion therapies such as chemotherapy, immunotherapy, and biologics; surgical procedures; and oral and specialty medications-ensuring patients receive medically necessary care without delays. You will work closely with: • Providers and clinical staff on order review, documentation completeness, and peer-to-peer coordination, • Nurses and infusion schedulers to ensure authorizations are secured prior to every treatment appointment, • Surgery schedulers on surgical authorization timelines and operative plan documentation, • Pharmacy on specialty medication authorization and oral oncology coordination, • Billing and coding staff to ensure authorized services align with CPT, HCPCS, and ICD-10 requirements Your accuracy, urgency, and follow-through directly determine whether patients get to their care on time. What You'll Own Authorization Submission & Tracking • Obtain prior authorizations for infusion therapies (chemotherapy, immunotherapy, biologics, and supportive medications), surgical procedures, and oral and specialty medications., • Submit authorization requests via payer portals, electronic systems, phone, and fax with complete and payer-compliant documentation., • Track authorization status across all active requests and proactively follow up with insurance carriers to secure timely determinations., • Ensure authorizations are in place prior to scheduled infusion appointments, clinic visits, surgeries, and medication dispensing-without exception. Documentation & Payer Compliance • Review provider orders, clinical notes, operative plans, and supporting documentation to ensure completeness and payer compliance before submission., • Verify insurance benefits, coverage criteria, and payer-specific requirements including step therapy, site-of-care rules, and clinical guidelines., • Maintain accurate, up-to-date documentation in the EMR and authorization tracking systems., • Stay current on payer policies, clinic workflows, and regulatory standards impacting outpatient services. Denials, Appeals & Communication • Communicate authorization approvals, denials, and pending requirements to providers, nurses, surgery schedulers, pharmacy, and front-desk teams in a timely and clear manner., • Coordinate peer-to-peer reviews and appeal processes with providers and leadership when authorizations are denied or delayed., • Collaborate with billing and coding staff to ensure authorized services align with CPT, HCPCS, ICD-10 codes, and payer requirements., • Maintain strict compliance with HIPAA, organizational policies, and payer regulations at all times. What Success Looks Like First 90 Days • Independently managing the full authorization workflow for infusion, surgical, and medication services., • Zero preventable care delays due to missing or late authorizations., • Strong working relationships established with clinical, scheduling, pharmacy, and billing teams. First 6 Months • Recognized as a reliable, high-accuracy resource across the clinical and administrative team., • Proactively identifying payer policy changes and surfacing authorization risks before they impact patient care. First Year • Viewed as a culture carrier and operational anchor for the authorization function., • Measurable contribution to clean authorization rates, denial reduction, and on-time care delivery., • Consistently embodying the Optimum Standard. Who Thrives Here We want people who bring relentless positivity, a hunger to learn, and the drive to elevate everyone around them. You will likely thrive if: • You take ownership rather than waiting for direction., • You believe details matter., • You enjoy solving problems and seek continuous improvement., • You care deeply about patients and their families., • You value teamwork and accountability equally., • You're coachable, curious, and committed to mastery. What You Bring Required • High school diploma or equivalent; Associate's degree preferred., • 2+ years of prior authorization experience in healthcare revenue cycle., • Demonstrated experience with medication and procedural authorizations., • Knowledge of commercial insurance, Medicare, Medicaid, and managed care plans., • Proficiency with EMR systems and insurance payer portals., • Strong organizational skills with the ability to manage multiple active authorization requests simultaneously., • Excellent written and verbal communication skills with a patient-centered approach. Preferred • Prior experience in a clinic, outpatient specialty practice, or ambulatory surgery setting., • Experience with oncology, infusion services, or surgical scheduling workflows., • Knowledge of oral oncolytics and specialty pharmacy coordination., • Familiarity with CPT, HCPCS, ICD-10 coding and medical necessity documentation. Our Culture We act with courage and embrace accountability. We serve with precision and hold ourselves to impeccable standards-then raise them. We reject mediocrity and the comfort of "good enough." We measure success not only by outcomes, but by the integrity, excellence, and humanity we bring to every interaction. Way Better. Extraordinary by Design. If you crave mastery, meaning, and measurable impact-welcome home. Compensation & Benefits • Competitive salary, • Health benefits, • 401(k), • Paid time off, • Professional development and continuing education support, • Opportunity to grow within the Optimum Platform This is a full-time, on-site position at our Albuquerque, New Mexico office.
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