Prior Authorization Specialist

Job not on LinkedIn

🔥 1 minute ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

DeliverHealth

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

Healthcare • Healthcare Insurance • Artificial Intelligence

DeliverHealth is an innovative company that specializes in providing advanced technology solutions and services to improve healthcare operations. They focus on enhancing healthcare documentation and coding through the use of AI and generative languages. Their offerings include eSOne InstaNote for AI-generated healthcare documentation, autonomous coding with AI, digital health solutions to boost patient engagement, and seamless EHR integration. DeliverHealth is known for their expertise in reducing administrative burdens, improving patient care, and integrating digital healthcare platforms, all while ensuring data security with HITRUST i1 certification.

📋 Description

• Review end-to-end Prior Authorization workflows executed by InstaAuth for accuracy, completeness, clinical appropriateness, payer compliance, submission readiness, and automation quality • Audit AI-generated authorization packages, including clinical summaries, supporting documentation, physician notes, diagnosis and procedure codes, medical necessity narratives, attachments, clinical evidence, questionnaires, and payer-specific forms • Evaluate AI decision quality, including documentation deficiencies, clinical evidence recommendations, payer-specific requirements, coding inconsistencies, authorization exceptions, urgency, and clinical recommendations • Conduct structured AI quality audits measuring workflow accuracy, automation success, clinical accuracy, documentation completeness, medical necessity validation, payer rule compliance, precision, recall, false-positive and false-negative rates, human intervention, and exception handling • Maintain quality scorecards and trend analyses • Provide structured feedback to Product Management, AI Engineering, R&D, and related teams on workflow failures, automation opportunities, payer logic, AI reasoning, prompts, workflow optimization, user interface, automation, and confidence scoring • Participate in recurring Product Quality Review meetings • Develop and maintain payer-specific authorization rules, clinical policy libraries, authorization scenarios, gold-standard reference cases, exception workflows, escalation guidelines, authorization knowledge bases, and payer-specific clinical documentation requirements • Review workflows across specialties including 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 • Translate operational insights into product requirements and acceptance criteria • Produce weekly validation reports, quality scorecards, false-positive and false-negative analyses, workflow failure reports, automation gap assessments, root cause analyses, enhancement recommendations, payer feedback reports, specialty optimization recommendations, gold-standard test cases, and monthly AI performance trend reports

🎯 Requirements

• Bachelor's degree in Nursing, Health Information Management, Medicine, Physician Assistant Studies, or a related clinical field • 5+ years of Prior Authorization experience within provider organizations, health systems, payer organizations, or Revenue Cycle Management • Strong understanding of medical necessity documentation • Experience with commercial, Medicare, and Medicaid prior authorization requirements • Knowledge of payer portals and authorization workflows • Experience with ICD-10-CM, CPT, and HCPCS coding fundamentals • Familiarity with Electronic Health Records (EHRs) and practice management systems • Experience with AI-assisted workflow solutions is preferred • Preferred credentials include RN / BSN, RHIA, RHIT, PA, or NP