Prior Authorization Specialist

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