Prior Authorization Manager

Hourly Contract
Remote – United States
$105/hour

About the Role

We are seeking experienced Prior Authorization Managers with clinical and medical expertise to evaluate AI tools designed to improve prior authorization workflows.

The role requires strong knowledge of medical necessity criteria, payer requirements, utilization management, and clinical review processes.

Responsibilities

• Manage prior authorization workflows for medical and clinical services across multiple payer types.

• Review clinical documentation against InterQual, MCG, or payer-specific medical necessity criteria.

• Evaluate AI-generated authorization recommendations and clinical justification drafts.

• Coordinate with clinical staff, physicians, and payers to obtain timely approvals.

• Track authorization status, denials, and appeals to identify workflow improvement opportunities.

• Develop and maintain SOPs for authorization submission, follow-up, and escalation.

• Monitor approval rates, turnaround times, and denial rates.

• Ensure compliance with payer requirements, CMS guidelines, and clinical review criteria.

• Provide structured feedback on AI-generated outputs for training datasets.

Requirements

• 5+ years of experience in prior authorization, utilization management, or clinical review, including at least 2 years in a management role.

• Strong clinical knowledge of medical necessity criteria, including InterQual, MCG, or equivalent.

• Experience with commercial, Medicare Advantage, and Medicaid authorization requirements.

• Experience managing authorization workflows across multiple specialties and service types.

• Proficiency with authorization management systems and EHR platforms such as Epic, Cerner, or equivalent.

• Excellent written and verbal English communication skills.

• Strong attention to detail and ability to evaluate clinical documentation and AI-generated content.

Preferred Qualifications

• Clinical licensure (RN, LPN, or equivalent) or CPUR/CPUM certification.

• Experience with appeals and peer-to-peer review processes.

• Familiarity with CMS prior authorization rules and the No Surprises Act.

• Experience in physician office, hospital, or health plan authorization operations.

• Familiarity with AI tools and AI-generated clinical content.

Contract Details

• Type: Hourly Contract

• Location: Remote – United States

• Compensation: $105/hour

• Engagement: Independent contractor

• Schedule: Flexible

• Payment: Weekly

• H1-B/STEM OPT: Not supported

• Projects may be extended, shortened, or concluded early based on needs and performance.