Payor Clearance Specialist

Job Description

The Payor Clearance Specialist supports revenue cycle and patient access operations by managing complex insurance authorization requirements for medical services, procedures, and treatments. This role requires hands-on experience obtaining prior authorizations for infusions, oncology treatments, radiology services, and high-dollar medications, as well as managing insurance denials and appeals. The specialist works closely with insurance companies, healthcare providers, and internal clinical teams to secure approvals, resolve coverage issues, and help prevent delays in patient care.

Earnings

$50,000-65,000+ annually (depending on experience) salary

Duties

• Manage prior authorization requests for infusions, oncology treatments, radiology services, and high-dollar medications, ensuring all insurance requirements are met.
• Review insurance policies, medical necessity criteria, and clinical documentation to determine authorization requirements and support approval.
• Submit authorization requests and communicate with insurance companies regarding coverage criteria, pending requests, and approval decisions.
• Manage insurance denials and appeals, including reviewing denial reasons, gathering supporting clinical documentation, preparing appeal submissions, and following up on determinations.
• Collaborate with physicians, clinical staff, and other departments to obtain missing documentation and address insurance-related barriers to treatment.
• Track authorization statuses, maintain accurate records, and ensure requests, appeals, and follow-ups are completed within required timeframes.
• Identify recurring authorization issues and escalate complex cases when additional review or intervention is needed.
• Communicate authorization outcomes and outstanding requirements to appropriate internal teams.
• Maintain patient confidentiality and comply with organizational policies and insurance requirements

Requirements

• Direct, hands-on prior authorization experience involving infusions, oncology, radiology, and high-dollar medications.
• Experience handling insurance denials and appeals, including investigating denial reasons, coordinating supporting documentation, and pursuing reconsideration or approval.
• Strong knowledge of medical insurance requirements, authorization processes, and medical necessity criteria.
• Experience communicating with insurance companies and healthcare providers to resolve complex authorization issues.
• Ability to review clinical documentation, manage multiple cases, and meet time-sensitive deadlines.
• Strong attention to detail, organization, problem-solving, and follow-through.
• Excellent written and verbal communication skills.
• Proficiency with electronic health records, insurance portals, and standard computer applications.

Ideal Candidate

• The ideal candidate has substantial experience managing complex specialty medication and procedure authorizations, particularly in oncology, infusion services, radiology, and high-cost medications. They should be comfortable navigating insurance requirements, addressing denials, preparing appeals, coordinating clinical documentation, and following cases through resolution. Candidates with experience in hospital revenue cycle departments, specialty clinics, infusion centers, oncology practices, or centralized authorization teams are encouraged to apply.