Clinical Consultant Authorization Platform

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

Benefits offered by this job

Medical insurance

Retirement plan

Paid time off

Wellness program

Job summary

Florida Blue seeks a Clinical Consultant to translate approved medical policy and utilization criteria into platform requirements, validate outputs, and ensure regulatory readiness. You will collaborate with Medical Directors, Compliance, Legal, Product, Engineering, Analytics, and AI safety teams to align clinical governance with the Authorization Platform.

This hybrid role involves preparing clinician readiness materials, guiding internal adoption, and supporting external partner integrations

Qualifications

• 6+ years of related work experience in utilization management or payer/provider environments.
• Clinical credential or equivalent clinical operations background.
• Strong understanding of medical policy development and regulatory requirements.

Responsibilities

• Translate clinical policy and criteria into platform requirements and decision logic.
• Validate outputs against policy, historical decisions, and documentation standards.
• Develop clinical validation plans, testing rubrics, and validation summaries.
• Collaborate with cross-functional teams to ensure governance and regulatory readiness.
• Create escalation criteria and human-review processes for high-risk cases.
• Support clinician adoption and communicate platform limitations and workflow impact.

Skills

Clinical policy

Utilization management

Prior authorization

Health informatics

Education

Bachelor's degree

Clinical credential (RN/MD/DO)

Tools

HL7/FHIR knowledge

Job description

The Clinical Consultant provides clinical translation, validation, and adoption support for the Authorization Platform. This role ensures approved medical policy, utilization management criteria, and clinical workflow expectations are accurately reflected in platform design while maintaining appropriate human oversight, clinical defensibility, and regulatory readiness. The Clinical Consultant uses technical knowledge in influencing and collaborating and negotiating with internal stakeholders (functional subject matter experts and senior executives) as well as external provider systems and health plan partners to ensure understanding of requirements needed to advance, automate, and transform the authorization process and platform.

Job duties include but are not limited to:

• Translates approved medical policy, utilization management criteria, benefit rules, and clinical guidelines into clear platform requirements and decision logic
• Supports development of decision trees, escalation pathways, clinical guardrails, and case-handling rules for priority authorization use cases
• Designs clinical requirements and decision logic documentation for priority authorization use cases
• Validates platform outputs against approved policy, historical decision patterns, clinician expectations, and documentation standards
• Builds clinical validation plan, testing rubric, and summary of validation findings
• Partners with Medical Directors, Compliance, Legal, Product, Engineering, Analytics, and AI safety teams to support governance, human oversight, bias monitoring, and regulatory readiness
• Identifies clinical risks, unclear reasoning, inappropriate automation, workflow gaps, and policy interpretation issues requiring escalation
• Creates escalation and human-review criteria for complex, uncertain, or high-risk cases
• Develops issue log to monitor and document policy gaps, clinical exceptions, accuracy and safety concerns, and required decisions
• Supports clinician adoption internally and across partner organizations by explaining platform purpose, limitations, required human review, workflow impact, and safe-use expectations
• Serves as the clinical subject matter expert bridging hospital systems, health plans, and technology teams to gather requirements, influence decision-making, and ensure solutions meet clinical and operational standards
• Creates clinician-facing readiness materials
• Delivers monthly senior executive leadership updates summarizing progress, risks, decisions needed, and launch considerations

Job Requirements:

• 6+ years related work experience. Experience Details: Experience in utilization management, care management, prior authorization, medical policy, clinical quality, clinical operations, or related payer/provider environment. Expert level health informatics
• Related Bachelor’s degree or additional related equivalent work experience
• Clinical credential or equivalent clinical operations background (RN, MD, or DO), or senior clinical operations leader)
• Strong understanding of medical policy development and interpretation, evidence-based medicine, clinical criteria, authorization workflows, documentation standards, and and clinical governance
• Demonstrated ability to identify and mitigate clinical and operational risks in healthcare systems
• Experience with healthcare data standards (ANSI, HL7, FHIR, or similar) and interoperability requirements
• Experience translating clinical requirements into operational workflows, system requirements (technical specifications and validation rules), decision support logic, or technology-enabled process design
• Knowledge of healthcare compliance, regulatory requirements, and quality standards
• Demonstrated experience in building productive relationships with various internal and external stakeholders and partners including provider systems and health plan senior executives, medical directors, and subject matter experts

Preferred:

• Experience with healthcare technology, health / clinical informatics, AI-enabled tools, quality improvement, regulatory readiness, or implementation of new clinical workflows
• Experience with AI/ML model validation from a clinical perspective (bias detection, outcome validation, safety testing)
• Familiarity with testing methodologies and prompt injection risks in clinical AI systems
• Experience designing human-in-the-loop workflows and escalation protocols for clinical decisions
• Understanding of data governance, sensitive data classification, and privacy-preserving analytics in healthcare
• Prior involvement in multi-stakeholder healthcare initiatives or interoperability projects
• Experience with agile or iterative development methodologies

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

This position offers a hybrid work arrangement which combines flexibility with in-office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate or regional offices may be required.

What We Offer:

As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan including employer match;
• Paid time off, volunteer time off, 10 holidays and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $109,300 - $177,600

Typical Annualized Hiring Range: $109,300 - $136,600

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.