Prior Authorization Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess end-to-end Prior Authorization workflows performed by InstaAuth for precision, thoroughness, clinical appropriateness, compliance with payer guidelines, readiness for submission, and quality of automation.

• Audit authorization packages generated by AI, which encompass clinical summaries, supporting documentation, physician notes, diagnosis and procedure codes, narratives on medical necessity, attachments, clinical evidence, questionnaires, and forms specific to payers.

• Analyze the quality of AI decision-making, focusing on documentation shortcomings, recommendations for clinical evidence, payer-specific requirements, inconsistencies in coding, exceptions in authorization, urgency, and clinical advice.

• Execute structured quality audits of AI, evaluating workflow accuracy, success in automation, clinical accuracy, completeness of documentation, validation of medical necessity, adherence to payer rules, and metrics such as precision, recall, rates of false positives and negatives, human intervention, and handling of exceptions.

• Maintain quality scorecards and perform trend analyses.

• Offer structured feedback to Product Management, AI Engineering, R&D, and other associated teams regarding workflow failures, opportunities for automation, payer logic, AI reasoning, prompts, workflow enhancements, user interface improvements, automation processes, and confidence scoring.

• Engage in regular Product Quality Review meetings.

• Create and uphold payer-specific authorization rules, libraries of clinical policies, scenarios for authorization, reference cases of gold standards, workflows for exceptions, guidelines for escalation, knowledge bases on authorization, and documentation requirements specific to payers.

• Review workflows across various specialties such as Orthopedics, Cardiology, Gastroenterology, Imaging & Radiology, Pain Management, Oncology, Behavioral Health, Neurology, Physical Therapy, and General Surgery.

• Collaborate with Product Managers, AI Engineers, Machine Learning Engineers, Prompt Engineers, Clinical Informaticists, Revenue Cycle Specialists, Prior Authorization Operations, QA Engineers, Data Scientists, and Customer Success teams.

• Transform operational insights into product requirements and acceptance criteria.

• Generate weekly validation reports, quality scorecards, analyses of false positives and negatives, reports on workflow failures, assessments of automation gaps, root cause analyses, recommendations for enhancements, feedback reports for payers, recommendations for specialty optimization, test cases of gold standards, and monthly trend reports on AI performance.

⛳️ Requirements

• A Bachelor's degree in Nursing, Health Information Management, Medicine, Physician Assistant Studies, or a similar clinical discipline.

• Over 5 years of experience in Prior Authorization within provider organizations, health systems, payer organizations, or Revenue Cycle Management.

• A solid understanding of medical necessity documentation.

• Familiarity with prior authorization requirements for commercial, Medicare, and Medicaid.

• Knowledge of payer portals and workflows for authorization.

• Experience with the fundamentals of ICD-10-CM, CPT, and HCPCS coding.

• Acquainted with Electronic Health Records (EHRs) and systems for practice management.

• Experience with AI-assisted workflow solutions is advantageous.

• Preferred qualifications include RN / BSN, RHIA, RHIT, PA, or NP.

🏝️ Benefits

• Comprehensive health insurance coverage.

• Competitive salary and performance-based bonuses.

• Opportunities for professional development and career advancement.

• Flexible work schedule and remote work options.

• Supportive and collaborative work environment.