Clinical Authorization Platform Specialist

Florida-Blue-; Jacksonville (FL); Hybrid; USD 109,000 - 178,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Life and travel benefits

Retirement Savings Plan with employer

Paid time off and holidays

Wellness programs

Job summary

Florida Blue seeks a Clinical Consultant to translate clinical policy into platform requirements, validate outputs, and support governance and regulatory readiness. You will collaborate across Medical Directors, Compliance, Legal, Product, Engineering, Analytics, and AI safety teams to ensure safe and compliant automated authorization.

The role includes designing escalation protocols, developing validation rubrics, and delivering executive updates on progress, risks, and launch considerations.

Qualifications

• Experience in utilization management, care management, or prior authorization in payer/provider settings.
• Strong understanding of medical policy development and clinical governance.
• Ability to translate clinical requirements into operational workflows and decision logic.

Responsibilities

• Translate clinical policy into platform requirements and decision logic.
• Develop decision trees, escalation pathways, and clinical guardrails.
• Document clinical requirements and validation rules for priority use cases.
• Validate platform outputs against policy and clinician expectations.
• Create clinical validation plans, testing rubrics, and summary findings.
• Collaborate with Medical Directors, Compliance, Legal, Product, Engineering, Analytics, and AI safety.
• Identify risks and escalation needs for complex cases.
• Develop escalation criteria for human review and log policy gaps.

Skills

Utilization management

Care management

Prior authorization

Medical policy

Clinical operations

Health informatics

Stakeholder collaboration

Regulatory readiness

Education

Bachelor’s degree or related equivalent

Clinical credential (RN/MD/DO) or senior clinical operations leader

Tools

HL7/FHIR knowledge

ANSI data standards

Job description

Florida Blue seeks a Clinical Consultant to translate clinical policy into platform requirements, validate outputs, and support governance and regulatory readiness. You will collaborate across Medical Directors, Compliance, Legal, Product, Engineering, Analytics, and AI safety teams to ensure safe and compliant automated authorization.

The role includes designing escalation protocols, developing validation rubrics, and delivering executive updates on progress, risks, and launch considerations.