ABOUT THIS ROLE

We are an AI company building tools for US health insurance payer operations — specifically for claims adjudication and prior authorisation. Our AI processes claim submissions, applies benefit rules, flags edits, and makes authorisation recommendations — the same functions that payer operations teams handle daily for US commercial, Medicare, or Medicaid plans. We need people who have personally worked these queues in a US payer environment and can tell us, from daily experience, whether the AI decisions make sense.

WORKFLOWS COVERED

Claims adjudication — applying benefit rules, running claim edits, generating EOBs, managing denials and appeals for US health plans
Prior authorisation processing — reviewing clinical criteria (MCG, InterQual), approving or denying authorisation requests for medical procedures
Utilisation management — concurrent review, discharge planning, medical necessity determinations
Coordination of benefits (COB) and duplicate claim detection

WHAT YOU WILL DO

Share how claims adjudication and prior authorisation work in practice in a US payer environment — the decision logic, the edge cases, and what actually drives approvals, denials, and appeals
Review claims processing workflows, prior auth criteria, or adjudication outputs and tell us where they diverge from real payer operations
Help us understand payer-specific nuances — edit logic, clinical criteria application, coordination of benefits — from someone who has worked production queues in a US health plan or BPO
Advise on what good payer operations looks like and where process descriptions or decision outputs miss the mark for a real US healthcare environment

YOU ARE THE RIGHT FIT IF

Minimum 3 years in claims adjudication or prior authorisation in a US health insurance context — commercial, Medicare Advantage, or Medicaid
Have personally adjudicated claims or processed prior auth requests — not just supervised or quality-checked
Know the platforms — Facets, TriZetto, QNXT, HealthEdge — from using them in production daily
Worked at organisations such as UnitedHealth Group, Aetna, Cigna, Humana, BCBS, or a healthcare BPO processing US payer work

NICE TO HAVE

CPC, COC, or CCS certification (AAPC/AHIMA)
RN, LPN, or clinical background — especially valuable for prior auth
Experience specifically with Medicare Advantage or Medicaid managed care plans

Prior Authorization Specialist