UM Nurse Analyst, Clinical Informaticist

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

📋 Description

• Analyze payer medical policy guidelines and create as well as maintain AI-driven decision trees that reflect medical necessity criteria.

• Convert health plan medical policies into organized decision pathways.

• Ensure clinical alignment of decision logic through validation.

• Assist in the implementation and upkeep of automated prior authorization workflows.

• Collaborate with teams in Product, Engineering, Medical Directors, and clinical informatics.

• Examine payer medical policy guidelines for medical necessity criteria associated with procedural/CPT codes.

• Develop and sustain attestation questions, decision pathways, and recommendation logic.

• Offer clinical insights to Product Operations, Engineering, implementation, account executives, and other customer-facing teams.

• Review and integrate updates from payer medical policies into existing decision trees.

• Aid in routine maintenance, change requests, and release readiness initiatives.

• Analyze audit results, customer feedback, and implementation observations to enhance decision trees.

• Report to the Clinical Manager of Availity’s Auth AI solution.

• Engage in necessary video meetings with camera enabled.

⛳️ Requirements

• Bachelor’s degree in nursing.

• Minimum of 3+ years of experience in a Utilization Management program with an insurer or healthcare provider, or equivalent clinical experience with knowledge of prior authorization submission practices.

• Proficient technology user with confidence in navigating new technologies and applications.

• Knowledgeable in interpreting medical records and recognizing how physicians may document conditions and findings.

• Strong grasp of medical necessity criteria, payer medical policy frameworks, prior authorization workflows, and utilization management principles.

• Familiarity with CPT, HCPCS, ICD-10, and the associated diagnosis, procedure, and documentation requirements.

• Capable of identifying policy ambiguities, edge cases, and workflow challenges that impact automated decision-making.

• Ability to clearly convey clinical rationale to technical, operational, and customer-facing stakeholders.

• Experience with reviewing and applying MCG, InterQual, or similar medical necessity criteria is preferred.

• Outstanding critical thinking and reasoning capabilities.

• Proficient in synthesizing complex, abstract problems and collaborating with team members of diverse skill sets.

• Self-driven, quick learner, and adept at multitasking.

• No sponsorship, in any form, is available.

• Must pass a drug test prior to starting employment.

• Must comply with United States employment eligibility verification requirements.

🏝️ Benefits

• Competitive salary.

• Bonus structure.

• HSA company contribution.

• Healthcare benefits.

• Vision benefits.

• Dental benefits.

• 401k match program available from day one.

• Unlimited PTO for salaried associates along with 9 paid holidays.

• Hourly associates begin with 19 days of PTO and receive the same holiday benefits.

• Wellness reimbursement up to $250/year for gym memberships, racing events, weight management programs, etc.

• Education reimbursement.

• Paid Parental Leave for birth and adoptive parents.

• Diversity & Inclusion teams and employee engagement groups.

• Continuous learning resources and access to industry/technology experts.

• Remote-first work environment.

• Camera/video capability for remote work.

• Opportunities for volunteer and community engagement.