Authorization Specialist

Position Summary

Oso Home Care is seeking a detail-oriented, customer-focused, and highly organized Authorization Specialist to join our Specialty Home Infusion Pharmacy team. The Authorization Specialist is responsible for obtaining timely insurance authorizations and ensuring patients receive medically necessary infusion therapies without unnecessary delays.

As a critical member of the Intake Department, the Authorization Specialist serves as the liaison between physicians, hospitals, insurance companies, case managers, specialty pharmacies, nursing staff, and internal departments to facilitate patient access to care. This position works closely with Intake Coordinators, Benefits Verification Specialists, Reimbursement Specialists, Clinical Pharmacists, Nurses, and Sales Representatives to ensure authorizations are obtained accurately, efficiently, and in compliance with payer requirements.

The ideal candidate possesses strong analytical skills, extensive knowledge of commercial and government insurance plans, prior authorization processes, medical necessity guidelines, and infusion therapy reimbursement. This individual must be able to prioritize multiple referrals in a fast-paced healthcare environment while maintaining exceptional customer service and attention to detail.

Essential Duties and Responsibilities

Prior Authorization Management

• Review new patient referrals to determine authorization requirements based on payer guidelines and therapy ordered.
• Submit prior authorization requests to commercial insurance carriers, Medicare Advantage plans, Medicaid Managed Care plans, HMOs, PPOs, IPA groups, and other third-party payers.
• Prepare and submit complete authorization packages including physician orders, clinical documentation, laboratory results, progress notes, infusion plans, and supporting medical necessity documentation.
• Ensure authorizations are submitted accurately and within departmental turnaround standards.
• Monitor authorization status daily and proactively follow up with insurance companies to prevent delays in patient care.
• Obtain authorization extensions, additional visits, continuation of therapy authorizations, and recertifications as required.
• Document all authorization activity accurately within the electronic medical record and payer portals.

Insurance Coordination

• Verify patient eligibility and benefits in collaboration with Benefits Verification Specialists.
• Interpret insurance coverage guidelines for specialty infusion medications and nursing services.
• Understand payer-specific authorization requirements for:
  • Commercial insurance
  • Medicare
  • Medicare Advantage
  • Medicaid
  • Managed Care Organizations
  • Workers' Compensation (when applicable)
• Review benefit limitations, authorization requirements, frequency limitations, and medical policies.
• Communicate insurance requirements to internal departments and referral sources.

Clinical Documentation Review

• Review physician orders for completeness and medical necessity.
• Ensure documentation supports payer requirements prior to submission.
• Coordinate with physicians' offices to obtain:
  • Signed physician orders
  • History & Physical
  • Progress notes
  • Laboratory results
  • Culture reports
  • Imaging reports
  • Medication history
  • Other required documentation
• Identify missing clinical documentation and coordinate timely follow-up.

Payer Communication

• Develop professional working relationships with payer representatives and utilization review nurses.
• Respond to requests for additional information.
• Participate in peer-to-peer review coordination when requested by physicians.
• Escalate complex authorization issues appropriately.
• Track payer response times and identify trends affecting patient access.

Appeals Management

• Assist with first-level and subsequent appeals for denied authorization requests.
• Gather supporting documentation necessary for appeal submissions.
• Coordinate with pharmacists, nurses, physicians, and reimbursement staff during appeal processes.
• Monitor appeal deadlines and ensure timely submissions.
• Maintain detailed records of appeal outcomes.

Collaboration

Work closely with:

• Intake Coordinators
• Benefits Verification Specialists
• Reimbursement Specialists
• Billing Department
• Clinical Pharmacists
• Home Health Nursing
• Ambulatory Infusion Center (AIC)
• Physician Offices
• Hospital Case Managers
• Sales & Business Development Representatives
• Referral Coordinators

to ensure patients begin therapy as quickly and efficiently as possible.

Regulatory Compliance

• Maintain compliance with:
  • CMS regulations
  • Medicare guidelines
  • HIPAA Privacy Rules
  • ACHC Accreditation Standards
  • California pharmacy regulations
  • Commercial payer policies
  • Company policies and procedures
• Maintain patient confidentiality at all times.
• Participate in quality improvement initiatives and departmental audits.

Documentation

• Maintain complete and accurate documentation within the electronic medical record.
• Document:
  • Authorization status
  • Dates submitted
  • Authorization numbers
  • Effective dates
  • Visit limitations
  • Approved medications
  • Approved nursing visits
  • Communication with payers
• Maintain accurate electronic referral tracking.

Customer Service

• Provide exceptional customer service to patients, families, physicians, referral sources, hospitals, and internal departments.
• Respond promptly to authorization inquiries.
• Communicate authorization status professionally and accurately.
• Maintain positive relationships with referral sources through timely communication.

Minimum Qualifications

• High School Diploma or equivalent required.
• Associate's degree in Healthcare Administration, Medical Assisting, Business Administration, or related field preferred.
• Minimum two (2) years of prior authorization experience in:
  • Specialty Pharmacy
  • Home Infusion
  • Home Health
  • Hospital Case Management
  • Medical Group
  • Infusion Center
• Experience submitting authorizations to commercial and government payers.
• Experience utilizing payer portals and electronic authorization systems.

Preferred Qualifications

• Home Infusion experience strongly preferred.
• Specialty Pharmacy experience preferred.
• Knowledge of infusion therapies including:
  • IV Antibiotics
  • IVIG
  • Biologic therapies
  • TPN
  • Enteral Nutrition
  • Hydration
  • Chemotherapy support medications
  • Specialty injectable medications
• Knowledge of Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
• Experience working with CareTend, CPR+, Brightree, EnterpriseRx, or similar healthcare software.

Knowledge & Skills

• Thorough knowledge of prior authorization processes.
• Strong understanding of medical insurance terminology.
• Knowledge of:
  • HCPCS Codes
  • CPT Codes
  • ICD-10 Coding
  • Revenue Cycle processes
  • Medical necessity guidelines
• Strong organizational and time management skills.
• Ability to prioritize multiple urgent referrals simultaneously.
• Excellent written and verbal communication skills.
• Strong critical thinking and problem-solving abilities.
• Excellent attention to detail.
• Ability to work independently while functioning effectively within a multidisciplinary healthcare team.
• Intermediate proficiency with Microsoft Office Suite, Outlook, Excel, and electronic medical records.