UM Nurse Analyst (Clinical Informaticist)

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change.
At Availity , we're not just another Healthcare Technology company; we're pioneers reshaping the future of healthcare! With our headquarters in vibrant Jacksonville, FL, and an exciting office in Bangalore, India, along with an exceptional remote workforce across the United States, we're a global team united by a powerful mission.

We're on a mission to bring the focus back to what truly matters – patient care. As the leading healthcare engagement platform, we're the heartbeat of an industry that impacts millions. With over 2 million providers connected to health plans, and processing over 13 billion transactions annually, our influence is continually expanding.

Join our energetic, dynamic, and forward-thinking team where your ideas are celebrated, innovation is encouraged, and every contribution counts. We're transforming the healthcare landscape, solving communication challenges, and creating connections that empower the nation's premier healthcare ecosystem.
The position of UM Nurse Analyst (Clinical Informaticist) will report to the Clinical Manager of Availity ’s Auth AI solution. This position is responsible for the interpretation of payer medical policy guidelines and the construction and maintenance of AI-enabled decision trees that accurately reflect medical necessity criteria. The analyst translates health plan medical policies into structure decision pathways, validates clinical alignment of decision logic, and supports implementation and maintenance activities related to automated prior authorization workflows.

The role requires in-depth knowledge of utilization management principles, the role and purpose of medical necessity guidelines and prior authorization adjudication practices. This individual will work in a cross-functional environment and collaborate with Product, Engineering, Medical Directors and other clinical informatics teams to ensure decision tree logic remains clinically accurate, scalable, auditable, and aligned with payer medical policies. The successful candidate will be detail oriented with strong analytic reasoning skills, demonstrate strong communication and organizational skills while remaining open-minded, embracing change and the spirit of innovation.

Sponsorship, in any form, is not available for this position.

Location: Remote, US
Why you want to work on this team:

- Dynamic, collaborative group working on innovative technologies to disrupt the status quo and solve the problem of prior authorization in healthcare.

- Opportunity to work directly on AI technology and its application to the healthcare industry.

Education and Experience:

- Bachelor’s degree in nursing.

- At least 3+ years of experience in an Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices.

- “Computer smart” – General power user of technology and confident with navigating new technologies and applications.

- Familiarity and understanding of interpreting medical records to be able to identify how physicians may document conditions and findings.

- Strong understanding of medical necessity criteria, payer medical policy structure, prior authorization workflows, and utilization management principles.

- Working familiarity with CPT, HCPCS, ICD-10, diagnosis, procedure, and documentation requirements.

- Ability to identify policy ambiguities, edge cases, and workflow challenges impacting automated decision-making.

- Ability to communicate clinical rationale clearly to technical, operational, and customer-facing stakeholders.

- Experience reviewing and applying MCG, Int