Description
This role is for one of our clients
A leading AI lab advancing applied AI in healthcare is seeking experienced professionals from the infusions and specialty pharmacy (SP) domain to support its documentation and criteria review systems. The role focuses on ensuring that payer authorization and medical necessity criteria are accurately reflected and applied to clinical documentation. You will work with AI-generated outputs, validating determinations, reviewing them against payer coverage policies, and providing structured feedback to help refine automated decision-making standards.
This position is ideal for professionals with backgrounds in intake, case management, documentation review, or clinical review within the infusions or specialty pharmacy space who want to apply their expertise in a flexible, high-impact environment.
Requirements
Key Responsibilities:
- Review AI-generated clinical determinations for accuracy and compliance with payer criteria.
- Identify and flag inaccurate or unclear determinations, providing structured feedback for model improvement.
- Evaluate documentation against Medicare, Medicaid, and commercial payer coverage policies.
- Analyze and interpret insurance policies, LCDs, and related materials to validate decision logic.
- Collaborate with AI and product teams to enhance workflows and review standards.
- Maintain organized records and contribute to continuous process optimization.
Qualifications:
Required:
- Hands-on experience in infusions or specialty pharmacy operations (intake, documentation review, case management, or clinical review).
- Strong understanding of payer authorization processes and compliance requirements.
- Ability to interpret and apply insurance coverage policies to real-world clinical cases.
- Highly detail-oriented, organized, and confident in making policy-driven decisions.
- Comfortable working independently in a remote setup.
Preferred:
- 4+ years of experience in the infusions/specialty pharmacy field.
- Familiarity with Medicare, Medicaid, and commercial payer guidelines.
- Working knowledge of HCPCS codes, NDCs, and common infusion drug categories (neurology, immunology, etc.).
- Experience handling prior authorizations, audits, or appeals.
- Tech-savvy and comfortable integrating AI tools into clinical review workflows.