JOB OVERVIEW

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. The specialist will review AI-generated prior authorization requests, validate clinical documentation and payer requirements, identify workflow failures, false approvals, false denials, missing information, and automation gaps, and provide structured feedback to Product Management, AI Engineering, and R&D teams.

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.

The role serves as the bridge between Prior Authorization operations, payer requirements, clinical documentation, revenue cycle management, and AI product development.

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

KNOWLEDGE, SKILLS, & ABILITIES

TECHNICAL KNOWLEDGE

Strong understanding of:

Prior Authorization workflows
Medical Necessity
Utilization Management
Payer Policies
Clinical Guidelines
ICD-10-CM
CPT
HCPCS
Revenue Cycle Management
Clinical Documentation
Healthcare Compliance
AI-assisted clinical workflow automation
Electronic Health Records (Epic, athenahealth, Cerner, eClinicalWorks, etc.)

CORE COMPETENCIES

Strong clinical judgment
Excellent analytical skills
Attention to detail
Ability to identify documentation gaps
Root cause analysis
Data-driven decision making
Effective written communication
Cross-functional collaboration
Continuous improvement mindset
Passion for healthcare AI and clinical innovation Strong analytical thinking
Clinical reasoning
Attention to detail
Root cause analysis
Process improvement
Excellent written communication
Cross-functional collaboration
Data-driven decision making
Customer-centric mindset
Passion for healthcare AI innovation

REQUIRED 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

Prior Authorization Specialist

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