Prior Authorization Specialist
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AI Summary
The specialist will evaluate the quality, accuracy, and efficiency of AI-driven prior authorization workflows within the InstaAuth platform. They will provide structured feedback to product and engineering teams to improve automation capabilities and clinical reliability.
JOB OVERVIEW
DeliverHealth is seeking an experienced Prior Authorization (PA) Specialist to support the continuous improvement of InstaAuth, DeliverHealth's AI-powered and agentic Prior Authorization platform.
The primary responsibility of this role is to evaluate the quality, accuracy, completeness, and efficiency of the AI-driven Prior Authorization workflows executed by InstaAuth. The specialist will review AI-generated prior authorization requests, validate clinical documentation and payer requirements, identify workflow failures, false approvals, false denials, missing information, and automation gaps, and provide structured feedback to Product Management, AI Engineering, and R&D teams.
This is not an operational Prior Authorization processing role responsible for submitting authorizations on behalf of providers. Instead, this is a Product Quality and Clinical AI role focused on continuously improving the intelligence, reliability, and automation capabilities of the InstaAuth platform.
The role serves as the bridge between Prior Authorization operations, payer requirements, clinical documentation, revenue cycle management, and AI product development.
JOB DUTIES & RESPONSIBILITIES
1. Validate AI-Driven Prior Authorization Workflows
Review end-to-end Prior Authorization workflows executed by InstaAuth to determine whether the AI:
Correctly identified procedures requiring prior authorization.
Selected the appropriate payer-specific workflow.
Collected all required clinical documentation.
Retrieved the correct payer criteria and medical policies.
Completed authorization forms accurately.
Identified missing clinical information.
Applied payer rules correctly.
Generated appropriate clinical justification.
Routed cases to the correct workflow.
Recommended the appropriate next action.
Assess whether each workflow is:
Accurate
Complete
Clinically appropriate
Compliant with payer requirements
Ready for submission
Optimally automated
2. Audit AI-Generated Authorization Packages
Review authorization packages generated by InstaAuth, including:
Clinical summaries
Supporting documentation
Physician notes
Diagnosis codes
Procedure codes
Medical necessity narratives
Attachments
Clinical evidence
Authorization questionnaires
Payer-specific forms
Verify that all required information has been captured and organized correctly.
3. Evaluate AI Decision Quality
Validate the AI's ability to:
Identify documentation deficiencies.
Recommend additional clinical evidence.
Detect payer-specific documentation requirements.
Flag missing medical necessity.
Suggest alternative documentation.
Identify coding inconsistencies.
Recognize authorization exceptions.
Determine authorization urgency.
Categorize findings as:
Correct recommendation
Missing recommendation
False positive
False negative
Incomplete workflow
Incorrect payer interpretation
Incorrect clinical recommendation
4. Perform AI Quality Audits
Conduct structured quality audits by measuring:
Workflow accuracy
Automation success rate
Clinical accuracy
Documentation completeness
Medical necessity validation
Payer rule compliance
Precision
Recall
False positive rate
False negative rate
Human intervention rate
Exception handling quality
Maintain quality scorecards and trend analyses.
5. Continuous Product Improvement
Partner closely with Product Management and Engineering teams by providing structured feedback on:
Workflow failures
Missing automation opportunities
Incorrect payer logic
AI reasoning gaps
Clinical documentation deficiencies
Prompt improvements
Workflow optimization
User interface improvements
Automation recommendations
Confidence scoring enhancements
Participate in recurring Product Quality Review meetings.
6. Payer Knowledge Management
Support Product and AI teams by developing:
Payer-specific authorization rules
Clinical policy libraries
Authorization scenarios
Gold-standard reference cases
Exception workflows
Escalation guidelines
Authorization knowledge base
Clinical documentation requirements by payer
Assist in maintaining payer rule accuracy as policies evolve.
7. Specialty-Specific Optimization
Review authorization workflows across specialties such as:
Orthopedics
Cardiology
Gastroenterology
Imaging & Radiology
Pain Management
Oncology
Behavioral Health
Neurology
Physical Therapy
General Surgery
Recommend specialty-specific workflow improvements.
8. Cross-Functional Collaboration
Work closely with:
Product Managers
AI Engineers
Machine Learning Engineers
Prompt Engineers
Clinical Informaticists
Revenue Cycle Specialists
Prior Authorization Operations
QA Engineers
Data Scientists
Customer Success teams
Translate operational insights into actionable product requirements and acceptance criteria.
Key Deliverables
Weekly AI workflow validation reports
Prior Authorization quality scorecards
False positive and false negative analyses
Workflow failure reports
Automation gap assessments
Root cause analyses
Product enhancement recommendations
Payer-specific feedback reports
Specialty optimization recommendations
Gold-standard authorization test cases
Monthly AI performance trend reports
KNOWLEDGE, SKILLS, & ABILITIES
Technical Knowledge
Strong understanding of:
- Prior Authorization workflows
- Medical Necessity
- Utilization Management
- Payer Policies
- Clinical Guidelines
- ICD-10-CM
- CPT
- HCPCS
- Revenue Cycle Management
- Clinical Documentation
- Healthcare Compliance
- AI-assisted clinical workflow automation
- Electronic Health Records (Epic, athenahealth, Cerner, eClinicalWorks, etc.)
Core Competencies
- Strong clinical judgment
- Excellent analytical skills
- Attention to detail
- Ability to identify documentation gaps
- Root cause analysis
- Data-driven decision making
- Effective written communication
- Cross-functional collaboration
- Continuous improvement mindset
- Passion for healthcare AI and clinical innovation Strong analytical thinking
- Clinical reasoning
- Attention to detail
- Root cause analysis
- Process improvement
- Excellent written communication
- Cross-functional collaboration
- Data-driven decision making
- Customer-centric mindset
- Passion for healthcare AI innovation
REQUIRED QUALIFICATIONS
- 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.
PREFERRED QUALIFICATIONS
- Experience with AI-assisted workflow solutions is preferred.
- Preferred credentials include:
- RN / BSN
- RHIA
- RHIT
- PA
- NP
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