Prior Authorization Specialist

Prior Authorization Specialist

Role

The Prior Authorization Specialist will be a key member of the product team, supporting SmarterDx’s newest product launch to help health systems capture the full value of care delivered. Working directly with our Product, Design, and Data Science teams; you’ll use your deep hands-on knowledge from large health systems to guide how we design, test, and refine new product capabilities. You will bring creativity and clinical insight to provide feedback for our proprietary clinical AI models; ensuring they accurately reflect real-world workflows and payer behaviors. This is a unique opportunity to apply your prior authorization expertise in a cutting-edge health technology environment where your efforts will directly influence the next generation of healthcare optimization.

**This role is fully remote within the US**

What You’ll Do

• Act as SmarterDx’s internal expert on prior authorization workflows, payer requirements, and best practices
• Partner with product managers, engineers, designers, and data scientists to design and validate new product features focused on clinical intelligence for authorizations
• Review, organize, and label real-world prior authorization data to support model training and performance evaluation
• Identify and communicate gaps, edge cases, and nuances in prior authorization logic that influence product and technology-driven recommendations
• Evaluate our AI model outputs for accuracy, completeness, and clinical alignment
• Collaborate with the internal and external teams to translate customer needs into actionable product feedback
• Document payer-specific rules, coding variations, and decision patterns to inform our products
• Contribute to internal knowledge bases and help develop scalable QA and labeling processes for ongoing clinical validation

What You Bring

• RN or other clinical background required
• 5+ years of hands-on experience managing medical prior authorizations in a large health system, hospital, or multi-specialty clinic.
• Deep understanding of medical necessity documentation, CPT/ICD-10 coding, step therapy requirements, and payer-specific criteria.
• Proven experience submitting and managing outpatient prior authorizations across procedure, surgery, infusion and imaging authorizations; both interpreting and aligning clinical documentation and payer requirements
• Comfort working across multiple payer platforms and navigating denials (PA Denials, CO-197, etc) and appeals
• Strong analytical skills with the ability to explain workflow logic and exceptions clearly
• Curiosity and adaptability to work in a cross-functional, product-focused environment
• Experience using EMRs (Epic, Cerner, Meditech, etc.) and payer portals (Availity, CoverMyMeds, etc)

Nice To Haves

• Experience in claims, billing, or denial management. 
• Exposure to healthcare data annotation or model validation work.
• Experience in inpatient or pharmacy benefit prior authorizations
• PACS Prior Authorization Certified Specialist

Our Tech Stack

• Notion
• Figma
• Snowflake

• $115k to $140k base + equity 

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