Job Description

Job Title: Pre-Certification Specialist / Prior Authorization Specialist

Location: Knoxville, TN (100% On-site)

Schedule: Full-time (40 hours/week) | Standard Shift Options: 7:30 AM – 4:00 PM, 8:00 AM – 4:30 PM, or 8:30 AM – 5:00 PM

Pay Rate: $21.00 – $25.00/hour (Based on experience)

Position Type: Contract-to-Hire

Position Summary

We are seeking a detail-oriented, highly proactive Pre-Certification Specialist to manage end-to-end medical specialty drug prior authorizations. In this high-impact role, you will work closely with clinical staff, Central Business Office (CBO) teams, and major healthcare payors to secure prompt approvals for complex drug regimens, chemotherapy, and infusion therapies, ensuring patients receive vital treatments without delay.

Key Responsibilities

• Prior Authorization Management: Initiate, track, and secure timely prior authorizations for complex medical specialty drugs, chemotherapy, and specialty infusion regimens.
• Clinical Documentation & Submission: Compile and submit clinical justification (physician notes, lab results, ICD-10 diagnosis codes, and treatment regimen details) to payors to establish medical necessity.
• Payor Relations & Portals: Navigate regional and national payor portals (Availity, CoverMyMeds, payor-specific sites) and phone lines daily—focusing heavily on BlueCross (~30%), Medicare/Medicare Advantage (~30%), and Humana.
• Appeals & White-Bagging Navigation: Manage appeals and peer-to-peer workflows to address payor restrictions, navigating white-bagging mandates to support in-house buy-and-bill operations.
• Interdepartmental Liaison: Serve as a central communication link between the CBO, attending physicians, and clinic staff regarding authorization status updates, payor restrictions, and coverage delays.

Required Qualifications

• Experience: Minimum 2 years of direct experience performing medical insurance verification and prior authorizations.
• Specialization: Demonstrated background obtaining prior authorizations specifically for medications/drugs (experience limited to diagnostic imaging or basic procedures will not qualify).
• Coding Knowledge: Working knowledge of ICD-10, CPT, and HCPCS coding as it applies to medical necessity guidelines and payor coverage.
• Technical Skills: Hands-on proficiency using web-based payor portals (Availity, CoverMyMeds, and payor-specific web tools).

Preferred Qualifications

• Prior experience securing authorizations within Oncology, Hematology, Chemotherapy, or Specialty Infusion practices.
• Direct experience with Buy-and-Bill operations.
• Hands-on experience utilizing Athena IDX practice management software.
• Background as a Certified Medical Assistant (CMA), Licensed Practical Nurse (LPN), or Financial Counselor.

Why Join Us?

• Impactful Work: Directly support life-saving patient care by eliminating administrative delays for critical specialty treatments.
• Work-Life Balance: Enjoy predictable weekday hours with your choice of standard start times (7:30 AM, 8:00 AM, or 8:30 AM).
• Long-Term Growth: Opportunity to transition into a permanent role with a leading specialty healthcare network.

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