[Hiring] Prior Authorization Specialist @DeliverHealth Solutions

Role Description

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. 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.

Job Duties & Responsibilities

• 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
• 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.
• 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
• 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.
• 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.
• 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.
• 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.
• 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

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