[Hiring] Prior Authorization Specialist @Pearl

Role Description

We are seeking a highly experienced Prior Authorization Specialist to support complex ophthalmology cases within a high-growth healthcare operations environment. This role functions as a clinical escalation expert, handling high-complexity insurance authorizations, appeals, and medical necessity reviews for surgical and specialty procedures.

• You will serve as a key link between clinical workflows, US-based provider practices, and internal product/engineering teams, helping translate real-world authorization challenges into scalable system improvements.
• This is not a traditional back-office role—this is a high-ownership, problem-solving position where you will actively shape workflows and automation design.
• The ideal candidate thrives in ambiguous, fast-moving environments, has deep expertise in US payer systems, and is comfortable making judgment calls on complex clinical documentation requirements.

Your Impact

• You will ensure timely and accurate approvals for high-complexity ophthalmology procedures, directly impacting patient access to care.
• You will reduce authorization delays and denial rates by strengthening documentation quality and review processes.
• You will help identify automation opportunities that improve operational efficiency and reduce manual workload across the RCM function.
• You will contribute to continuous workflow improvement by translating real payer behavior into scalable process logic.
• You will elevate team quality by mentoring junior staff and establishing best practices for complex case handling.

Core Responsibilities

• Advanced Authorization Case Management – 40%
  • Manage end-to-end prior authorization processes for complex ophthalmology procedures.
  • Review clinical documentation to ensure medical necessity compliance (e.g., imaging, test results, physician notes).
  • Submit and manage appeals, reconsiderations, and payer follow-ups for denied cases.
• Clinical QA & Team Escalation Support – 25%
  • Act as escalation point for complex authorization cases from junior eligibility staff.
  • Conduct case audits to identify errors, gaps, and training opportunities.
  • Develop and maintain internal payer and policy knowledge documentation.
• Workflow Optimization & Product Collaboration – 20%
  • Collaborate with US-based product and engineering teams to map authorization workflows.
  • Identify automation opportunities and define logic for system improvements.
  • Report workflow failures, edge cases, and payer-specific exceptions.
• Stakeholder & Provider Coordination – 15%
  • Communicate with US provider offices to resolve missing documentation issues.
  • Coordinate across teams to ensure timely case resolution.
  • Participate in daily operational standups and SLA monitoring discussions.

Qualifications

• 5+ years of experience in US Healthcare RCM, specifically Prior Authorization.
• Strong experience handling complex specialty cases (ophthalmology, oncology, or surgical specialties preferred).
• Deep understanding of US payer systems, insurance workflows, and medical necessity requirements.
• Experience working with CPT, ICD-10 coding and clinical documentation review.
• Excellent written and verbal English communication skills.
• Ability to work independently in fast-paced, ambiguous environments.

Nice-to-Haves

• Experience in ophthalmology prior authorization workflows.
• Background in startup or early-stage healthcare operations environments.
• Experience collaborating with product or engineering teams on workflow design.
• Familiarity with denial management and appeals strategy at scale.

Tools Proficiency

• Must-Haves
  • Payer Portals (e.g., Availity, Optum, Medicare/Medicaid portals)
  • EMR/EHR systems (various provider systems)
  • Google Workspace (Docs, Sheets, Gmail)
  • Communication tools (Slack, Zoom)
• Nice-to-Haves
  • Automation or workflow tools (Zapier or similar)
  • Project management tools (Asana, Trello, Notion)
  • Data tracking or reporting dashboards

Benefits

• Competitive Salary: Based on experience and skills
• Remote Work: Fully remote—work from anywhere
• Team Incentives: Recognition for maintaining 100% CRM hygiene and on-time reporting
• Generous PTO: In accordance with company policy
• Health Coverage for PH-based talents: HMO coverage after 3 months for full-time employees
• Direct Mentorship: Guidance from international industry experts
• Learning & Development: Ongoing access to resources for professional growth
• Global Networking: Connect with professionals worldwide

Our Recruitment Process

• Application
• Screening
• Skills Assessment
• Top-grading Interview
• Client Interview
• Job Offer
• Client Onboarding

Ready to Join Us?

If this role aligns with your skills and goals, apply now to take the next step in your journey with Pearl.