Prior Authorization Specialist

Overview

CentraState Healthcare System, based in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace.

CentraState Medical Center is currently seeking a Prior Authorization Specialist. In this role, the specialist will review oncology therapy regimens and inpatient oncology admissions while also providing redundancy for radiation therapy, ensuring compliance with reimbursement guidelines. Responsibilities include securing pre-certifications, prior authorizations, and medical necessity approvals to prevent delays in treatment reimbursement. The specialist will also research denied services, explore alternative funding options, and monitor work queues through EPIC and/or Mosaiq. Additionally, they will collaborate with insurance companies on predeterminations, authorizations, and medical necessity verifications while tracking reports related to denials and other key processes.

Responsibilities

• Reviews, processes, and audits the medical necessity for each patient therapy treatment and all necessary required documentation.
• Communicates with nursing and medical staff to inform them of any restrictions or special requirements in accordance with insurance plans.
• Provides prompt feedback to physicians and leadership team regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
• Updates coding/payor guidelines for clinical staff. Tracks pathways and performs various other business office functions on an as needed basis.
• Obtains insurance authorization and pre-certification specifically for patient therapy services. Works as a patient advocate and functions as a liaison between the patient and payor to answer reimbursement questions and avoid insurance delays.
• Researches additional or alternative resources for non-covered therapy services to prevent payment denials.
• Provides a contact list for patient’s community resources including special programs, drugs, and pharmaceutical supplies and financial resources.
• Maintains thorough understanding and use of electronic medical record/s and payor websites.
• Adheres to confidentiality, state, federal, and HIPPA laws and guidelines with regards to patient’s records.
• Maintains a good working knowledge of therapy authorization requirements for all payors, state and federal regulatory guidelines for coverage and authorization.
• Works authorization queue daily and as needed.
• Performs other duties as requested or assigned.

Qualifications

• High School Diploma Or Equivalent required.
• Bachelor's Degree preferred.
• Minimum three (3) years medical insurance verification and authorization required.
• Oncology therapy experience required.
• Demonstrated working knowledge of contracts, insurance benefits, exclusions, and other billing requirements as well as claim forms, HMOs, PPOs, Medicare, Medicaid, and compliance program regulations.
• Ability to understand and navigate the payor adjudication process.
• Must possess a strong customer service and patient focused orientation.
• Demonstrated effective communication skills both verbally and written.
• Ability to multi-task, prioritize, and manage time effectively.
• Functional proficiency in computer software skills (i.e., Microsoft Word, Excel, Outlook, E-mail, etc.)
• Ability to work independently.
• Patient financial and practice management system experience in Epic and or other of electronic billing systems is preferred.
• Knowledge of medical terminology is required.

About Us

CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well.

Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and