Prior Authorization Manager for AI Evaluation

Lead clinical prior authorisation operations while evaluating and improving AI-driven workflows that aim to reduce administrative burden and improve patient access to care. This role combines hands-on management of prior authorisation processes with structured clinical review and annotation of AI-generated recommendations to help train and validate next-generation healthcare AI systems.

• Manage end-to-end prior authorisation workflows for medical and clinical services across commercial, Medicare Advantage, and Medicaid payer types.
• Review clinical documentation to assess medical necessity against InterQual, MCG, or payer-specific criteria.
• Evaluate AI-generated prior authorisation recommendations and clinical justification drafts for accuracy, completeness, and appropriateness.
• Coordinate with clinical staff, physicians, and payers to obtain timely authorisation approvals and to escalate when needed.
• Track authorisation status, denials, and appeal outcomes to identify and implement workflow improvements.
• Develop and maintain standard operating procedures for prior authorisation submission, follow-up, and escalation processes.
• Monitor KPIs including authorisation approval rates, turnaround times, and denial rates, and act on trends.
• Ensure compliance with payer requirements, relevant CMS guidelines, and clinical review criteria.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets and quality improvements.

• Minimum 5 years of experience in prior authorisation, utilisation management, or clinical review, with at least 2 years in a management role.
• Strong clinical background with working knowledge of medical necessity criteria such as InterQual, MCG, or equivalent.
• Deep familiarity with prior authorisation requirements for commercial plans, Medicare Advantage, and Medicaid.
• Proven experience managing authorisation workflows across multiple specialties and service types.
• Proficiency with authorisation management systems and EHR platforms, for example Epic, Cerner, or equivalent systems.
• Exceptional written and verbal English communication skills.
• High attention to detail and the ability to critically evaluate clinical documentation and AI-generated outputs.

• Clinical licensure such as RN, LPN, or equivalent, or relevant certification such as CPUR or CPUM.
• Experience with appeals and peer-to-peer review processes.
• Familiarity with CMS prior authorisation rules and the No Surprises Act.
• Background working in physician office, hospital, or health plan prior authorisation operations.
• Comfort evaluating AI-generated clinical content and experience working with AI tools is a plus.

Remote position, paid on an hourly basis. Specific weekly hours or schedule were not provided.

Pay rate: $105 per hour.

• Contribute to the development of frontier AI systems applied to healthcare operations.
• Collaborate with a leading AI research organization on projects that impact the healthcare revenue cycle.
• Gain exposure to cutting-edge AI workflows and help shape tools that improve patient access and reduce administrative burden.