[Hiring] UM Nurse Analyst @Availity

Role Description

The position of UM Nurse Analyst (Clinical Informaticist) will report to the Clinical Manager of Availity’s Auth AI solution. This position is responsible for:

• Interpretation of payer medical policy guidelines.
• Construction and maintenance of AI-enabled decision trees that accurately reflect medical necessity criteria.
• Translating health plan medical policies into structured decision pathways.
• Validating clinical alignment of decision logic.
• Supporting implementation and maintenance activities related to automated prior authorization workflows.

The role requires in-depth knowledge of:

• Utilization management principles.
• The role and purpose of medical necessity guidelines.
• Prior authorization adjudication practices.

This individual will work in a cross-functional environment, collaborating with:

• Product
• Engineering
• Medical Directors
• Other clinical informatics teams

The successful candidate will be:

• Detail-oriented with strong analytic reasoning skills.
• Demonstrating strong communication and organizational skills.
• Open-minded, embracing change and the spirit of innovation.

Qualifications

• Bachelor’s degree in nursing.
• At least 3+ years of experience in a Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices.
• “Computer smart” – General power user of technology and confident with navigating new technologies and applications.
• Familiarity and understanding of interpreting medical records to identify how physicians may document conditions and findings.
• Strong understanding of medical necessity criteria, payer medical policy structure, prior authorization workflows, and utilization management principles.
• Working familiarity with CPT, HCPCS, ICD-10, diagnosis, procedure, and documentation requirements.
• Ability to identify policy ambiguities, edge cases, and workflow challenges impacting automated decision-making.
• Ability to communicate clinical rationale clearly to technical, operational, and customer-facing stakeholders.
• Experience reviewing and applying MCG, InterQual, or similar medical necessity criteria preferred.

Requirements

• Exceptional critical thinking and reasoning skills.
• Ability to synthesize complex, abstract problems and collaborate effectively with team members with diverse skillsets to create solutions.
• Self-motivated and a quick learner with the ability to multi-task.

Benefits

• Competitive salary and bonus structure.
• Generous HSA company contribution.
• Healthcare, vision, and dental benefits.
• 401k match program available from day one.
• Unlimited PTO for salaried associates + 9 paid holidays.
• Hourly associates start at 19 days of PTO with all the same holiday benefits.
• Reimbursement up to $250/year for gym memberships, participation in racing events, weight management programs, etc.
• Education reimbursement available.
• Paid Parental Leave for both birth and adoptive parents.
• Opportunities to engage with community organizations through volunteer efforts.