Prior Authorisation Manager

About this role

You will support the evaluation and improvement of AI systems designed to streamline healthcare prior authorisation and utilisation management workflows. The role combines clinical knowledge, payer expertise, and operational leadership to assess medical necessity, review AI-generated authorisation recommendations, and improve clinical justification quality. You will help ensure AI outputs align with payer requirements, clinical review criteria, and regulatory standards while reducing administrative burden and improving patient access to care.

Prior Authorisation AI Expert

Responsibilities

• Prior authorisation management: Lead end-to-end authorisation workflows for medical and clinical services across multiple payer types.
• Medical necessity review: Assess clinical documentation against InterQual, MCG, or payer-specific criteria.
• AI output evaluation: Review AI-generated prior authorisation recommendations and clinical justification drafts for accuracy, appropriateness, and completeness.
• Payer coordination: Work with physicians, clinical teams, and payers to obtain timely authorisation approvals.
• Denial and appeal tracking: Monitor authorisation status, denials, and appeal outcomes to identify recurring issues and improvement opportunities.
• SOP development: Create and maintain procedures for authorisation submission, follow-up, escalation, and documentation.
• KPI monitoring: Track approval rates, turnaround times, denial rates, and related operational performance indicators.
• Compliance: Ensure workflows align with payer requirements, CMS guidelines, and applicable clinical-review criteria.
• AI training support: Annotate AI-generated outputs and provide structured clinical feedback for model-training datasets.

Qualifications

• Minimum 5+ years of experience in prior authorisation, utilisation management, clinical review, or related healthcare operations.
• At least 2 years in a management or leadership role.
• Strong clinical background with knowledge of InterQual, MCG, or equivalent medical-necessity criteria.
• Deep familiarity with commercial insurance, Medicare Advantage, and Medicaid prior authorisation requirements.
• Experience managing authorisation workflows across multiple specialties, procedures, and service types.
• Proficiency with prior authorisation management systems and EHR platforms such as Epic, Cerner, or equivalent systems.
• Strong ability to review clinical documentation and determine whether medical-necessity requirements are met.
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to critically evaluate clinical and AI-generated content.
• Must be based in the United States.