UM Nurse Analyst, Clinical Informaticist

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

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Availity

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2000

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 Secondary Market on 2021-07

Healthcare • Consulting • Logistics

Availity is a leading health information network that connects payers, providers, and technology partners in the healthcare industry. By facilitating over 13 billion clinical, administrative, and financial transactions annually, Availity streamlines payer-provider collaboration and enhances patient care through an integrated provider engagement platform. The company's solutions leverage artificial intelligence and interoperability to automate processes such as prior authorizations, revenue cycle management, and payment accuracy, ultimately reducing costs and improving efficiency across the healthcare ecosystem.

📋 Description

• Interpret payer medical policy guidelines and construct and maintain AI-enabled decision trees reflecting medical necessity criteria • Translate health plan medical policies into structured decision pathways • Validate clinical alignment of decision logic • Support implementation and maintenance of automated prior authorization workflows • Collaborate with Product, Engineering, Medical Directors, and clinical informatics teams • Review payer medical policy guidelines for medical necessity criteria related to procedural/CPT codes • Build and maintain attestation questions, decision pathways, and recommendation logic • Provide clinical guidance to Product Operations, Engineering, implementation, account executives, and other customer-facing teams • Review and incorporate payer medical policy updates into existing decision trees • Support routine maintenance, change requests, and release readiness efforts • Review audit findings, customer feedback, and implementation observations to improve decision trees • Report to the Clinical Manager of Availity’s Auth AI solution • Participate in required video meetings with camera enabled

🎯 Requirements

• Bachelor’s degree in nursing • At least 3+ years of experience in a Utilization Management program with an insurer or healthcare provider, or equivalent clinical experience with familiarity with prior authorization submission practices • General power user of technology and confident navigating new technologies and applications • Familiarity with interpreting medical records and identifying how physicians may document conditions and findings • Strong understanding of medical necessity criteria, payer medical policy structure, prior authorization workflows, and utilization management principles • Working familiarity with CPT, HCPCS, ICD-10, diagnosis, procedure, and documentation requirements • Ability to identify policy ambiguities, edge cases, and workflow challenges affecting automated decision-making • Ability to communicate clinical rationale clearly to technical, operational, and customer-facing stakeholders • Experience reviewing and applying MCG, InterQual, or similar medical necessity criteria preferred • Exceptional critical thinking and reasoning skills • Ability to synthesize complex, abstract problems and collaborate with team members with diverse skillsets • Self-motivated, quick learner, and able to multitask • Sponsorship, in any form, is not available • Must pass a drug test before beginning employment • Must meet United States employment eligibility verification requirements

🏖️ Benefits

• Competitive salary • Bonus structure • HSA company contribution • Healthcare benefits • Vision benefits • Dental benefits • 401k match program available on day one • Unlimited PTO for salaried associates + 9 paid holidays • Hourly associates start at 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 industry/technology experts • Remote-first work environment • Camera/video capability for remote work • Volunteer and community engagement opportunities