Prior Authorisation Manager

• Manage end-to-end prior authorisation workflows for medical and clinical services across multiple payer types.
• Review clinical documentation to assess medical necessity against InterQual, MCG, or payer-specific criteria.
• Evaluate AI-generated prior authorisation recommendations and clinical justification drafts for accuracy and appropriateness.
• Coordinate with clinical staff, physicians, and payers to obtain timely authorisation approvals.
• Track authorisation status, denials, and appeal outcomes to identify workflow improvement opportunities.
• Develop and maintain SOPs for prior authorisation submission, follow-up, and escalation processes.
• Monitor KPIs including authorisation approval rates, turnaround times, and denial rates.
• Ensure compliance with payer requirements, CMS guidelines, and clinical review criteria.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

• 5+ years of experience in prior authorisation, utilisation management, or clinical review, with at least 2 years in a management role.
• Strong clinical background with knowledge of medical necessity criteria (InterQual, MCG, or equivalent).
• Deep familiarity with commercial, Medicare Advantage, and Medicaid prior authorisation requirements.
• Experience managing authorisation workflows across multiple specialities and service types.
• Proficiency with authorisation management systems and EHR platforms (Epic, Cerner, or equivalent).
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to critically evaluate clinical documentation and AI-generated outputs.

• Clinical licensure (RN, LPN, or equivalent) or relevant certification (CPUR, CPUM).
• Experience with appeals and peer-to-peer review processes.
• Familiarity with CMS prior authorisation rules and the No Surprises Act.
• Background in physician office, hospital, or health plan prior authorisation operations.
• Familiarity with AI tools and comfort evaluating AI-generated clinical content.

Project and contracting process: Mercor. Applications continue on the provider's website.