Prior Authorization Specialist

JOB OVERVIEW

DeliverHealth is seeking an experienced Prior Authorization (PA) Specialistto 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 roleresponsible 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 analyt