Authorization Specialist

About the role

This position is responsible for managing complex and high-risk eligibility, authorization, and financial assistance cases within home infusion services. This role specializes in escalations, second-level appeals, complex reimbursement issues, and challenging copayment assistance scenarios. In addition, this position plays a key role in removing payer and financial barriers to care, ensuring timely patient access to therapy while maintaining compliance with payer requirements and organizational standards.

Essential Duties and Responsibilities

• Manage escalated authorization cases involving complex payer requirements and non-standard scenarios.
• Lead second-level appeals, including preparing detailed documentation, clinical justification, and payer communication.
• Troubleshoot and resolve complex Revenue Cycle Management related issues tied to authorization, denials, and reimbursement barriers.
• Manage challenging copayment assistance cases, including coordination with foundations, manufacturers, and internal teams.
• Identify potential areas for retraining and support management and intake training team to implement a training plan.
• Absorb intake, eligibility, and authorization workflows as needed.
• Serve as the subject matter expert on authorization workflows, payer policies, and escalation pathways.
• Work closely with intake, clinical, pharmacy, and billing teams to ensure seamless patient onboarding and continuity of care.
• Proactively identify risks to authorization approval or reimbursement and implement mitigation strategies.
• Assist with writing standard operating procedures, policies, information tools, and training tools.
• Maintain accurate, thorough documentation in all systems to ensure compliance and audit readiness.
• Identify trends in denials or escalation cases and recommend process improvements.
• Assist with any projects that require authorization, copay assistance, demographic entry, or eligibility expertise.

Job Requirements and Qualifications

• High school diploma or equivalent required.
• Associate or bachelor’s degree in health care or related field preferred.
• Minimum three (3) years of experience in healthcare authorizations, insurance verification, reimbursement, or revenue cycle operations, preferably in home infusion, specialty pharmacy, or a related healthcare setting.
• Experience managing prior authorizations, second-level appeals, and payer requirements for specialty therapies, infusion services, and high-cost medications.
• Knowledge of commercial, Medicare, and Medicaid payer guidelines, authorization processes, and reimbursement requirements.
• Working knowledge of HCPCS, CPT, and other applicable coding systems related to infusion and specialty pharmacy services.
• Experience obtaining authorizations and reimbursement for specialty, biologic, and high-cost medications.
• Understanding of revenue cycle management (RCM) processes and the impact of authorizations on reimbursement and claims outcomes.
• Experience navigating copay assistance, patient assistance, and other financial support programs for specialty therapy patients.
• Proficient experience with Microsoft Office including Word, Excel, PowerPoint, Outlook, Teams, and CPR+ software system or similar system preferred.

Skills and Competencies

• Strong knowledge of prior authorization processes, payer guidelines, and coverage requirements across commercial, Medicare, and Medicaid plans.
• Ability to interpret insurance benefits, medical necessity criteria, coverage determinations, and complex payer policies to support successful authorization and appeal outcomes.
• Proven ability to manage complex or escalated authorization cases, including denials, appeals, and difficult approvals.
• Understanding of revenue cycle management (RCM) processes and the impact of authorizations on reimbursement and financial outcomes.
• Strong critical thinking, analytical, and problem-solving skills with the ability to identify barriers and develop effective solutions.
• Excellent verbal and written communication skills, including the ability to communicate effectively in high-pressure or sensitive situations.
• Demonstrated ability to work independently, prioritize competing demands, and manage multiple cases simultaneously while maintaining accuracy and timeliness.
• Strong attention to detail and commitment to quality, compliance, and patient-centered service.

What We Offer

• Competitive compensation
• Benefits start on your 1st day of employment
• 401k w 4% match – no waiting or vesting period
• PTO / Floating Holidays / Paid Holidays
• Company paid life insurance, short term disability
• Employee Assistance programs to help with mental health / wellness
• Learning & Development Programs
• Perks… includes discounts on travel, cell phone, clothing and more…
• Generous employee referral program

Learn more about KabaFusion