Radiation Oncology Specialist

About the role

The Radiation Oncology Authorization Specialist is responsible for independently coordinating and managing medical necessity-based prior authorizations for radiation oncology services. Working in a high-volume, fast-moving environment, the Specialist applies payer coverage criteria and authorization requirements to ensure financial clearance for radiation oncology services prior to key milestones (consult, CT simulation, treatment start).

Responsibilities

• Review and manage radiation oncology authorization work queues and independently prioritize cases based on treatment start dates, urgency, payer requirements, and financial clearance risk.
• Prepare and submit payer-specific prior authorization requests for radiation oncology services, including physician consultation, simulation, IMRT, IGRT, SBRT, SRS, brachytherapy, and conventional radiation therapy.
• Interpret payer medical necessity criteria and apply the appropriate coverage guidelines.
• Review and synthesize clinical documentation including consult notes, treatment plans, pathology results, imaging reports, operative notes, laboratory data, and other associated imaging or treatment-related services as required by payer guidelines.
• Identify and gather the most relevant documentation to meet payer medical policy requirements for radiation therapy and related services.
• Track pending authorization requests in HER and follow up with health plans to obtain determinations within required timeframes.
• Respond to payer requests for additional clinical information and work to resolve issues that may delay authorization.
• Communicate authorization outcomes, denials, partial approvals, and payer limitations to appropriate clinical, scheduling, and operational teams.
• Maintain complete and accurate documentation of all authorization activity in the EMR and other designated systems.
• Coordinate provider-to-payer escalation processes when needed, including peer-to-peer reviews, letters of medical necessity, reconsiderations, and provider-supported appeals.
• Verify insurance eligibility, benefits, referral requirements, and authorization needs using electronic eligibility tools, payer portals, and direct payer communication.
• Support denial prevention and perform follow-up on authorization-related claim denials involving radiation oncology services.
• Aid in patient communication related to insurance authorization issues, coverage limitations, or denied services, and provide clear, professional customer service.
• Participate in process improvement efforts related to authorization workflow, payer trends, denial reduction, and operational efficiency.

Requirements

High school diploma required. Associate’s degree in business administration, management, healthcare, or related field preferred. Minimum of 1 year of relevant experience in a hospital, ambulatory, physician practice, oncology, or specialty authorization setting required. Relevant experience may include prior authorization, insurance verification, financial counseling, patient access, medical billing, revenue cycle operations, health insurance, healthcare administration, utilization review, or medical policy review. Epic Referrals/Authorizations and/or HB/PB workflow experience preferred. ARIA workflow familiarity as it relates to treatment readiness and documentation handoffs preferred. Experience working with third-party payers and authorization requirements preferred. Prior oncology or radiation oncology experience preferred.

Qualifications

Strong working knowledge of computer systems, electronic medical records, payer portals, and Microsoft Office applications. Demonstrated understanding of third-party payer guidelines, insurance plan structures, and prior authorization processes. Knowledge of medical terminology and basic clinical concepts, with preference for oncology and radiation oncology terminology to review and interpret clinical documentation and determine appropriate documentation to submit to support medical necessity. Strong analytical, organizational, and problem-solving skills. Ability to work independently, manage competing priorities, and meet deadlines within established workflows and policies, while maintaining confidentiality of sensitive patient information in accordance with HIPAA and organizational standards. Ability to communicate clearly and effectively with payers, providers, clinical staff, patients, and colleagues across departments while using sound judgment, professionalism, tact, and discretion in complex or sensitive situations. Ability to perform effectively in a high-volume, deadline-driven environment.

Skills

• Strong working knowledge of computer systems, electronic medical records, payer portals, and Microsoft Office applications.
• Demonstrated understanding of third-party payer guidelines, insurance plan structures, and prior authorization processes.
• Knowledge of medical terminology and basic clinical concepts, with preference for oncology and radiation oncology terminology to review and interpret clinical documentation and determine appropriate documentation to submit to support medical necessity.
• Strong analytical, organizational, and problem-solving skills.
• Ability to work independently, manage competing priorities, and meet deadlines within established workflows and policies, while maintaining confidentiality of sensitive patient information in accordance with HIPAA and organizational standards.
• Ability to communicate clearly and effectively with payers, providers, clinical staff, patients, and colleagues across departments while using sound judgment, professionalism, tact, and discretion in complex or sensitive situations.
• Ability to perform effectively in a high-volume, deadline-driven environment.