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 a