Prior Authorization Specialist

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 1. 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 2. 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. 3. 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 4. 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. 5. 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. 6. 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. 7. 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. 8. 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