Prior Authorisation Manager

DigiNo; Northern (KY); Hybrid; USD 90,000 - 115,000; Full time

Job summary

Mercor, in collaboration with a leading AI research lab, seeks experienced Prior Authorisation Managers with clinical expertise to guide AI-driven prior authorisation workflows across multiple payer types. You will review medical necessity criteria, coordinate with clinicians and payers, and help train AI systems to improve access to care.

Join a pioneering healthcare AI initiative that aims to streamline revenue cycle processes, ensuring timely authorisations while maintaining compliance with

Qualifications

• 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.

Responsibilities

• 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.

Skills

Clinical expertise

Payer review knowledge

English communication

Attention to detail

Leadership

Education

RN or LPN licensure

CPUR/CPUM certification

Tools

Epic

Cerner

Job description

Mercor is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Prior Authorisation Managers with clinical and medical expertise to support the evaluation of AI tools designed to streamline prior authorisation workflows. Your clinical knowledge of medical-necessity criteria, payer review processes, and utilisation management will help train AI systems to reduce administrative burden and improve patient access to care.

Responsibilities

• 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.

Requirements

• 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.

Preferred Qualifications

• 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.

Why Join?

• Contribute to the development of frontier AI systems in healthcare.

• Collaborate with a world-class AI research organisation.

• Gain exposure to cutting-edge AI workflows in healthcare revenue cycle management.

• Opportunity to work on high-impact projects shaping the future of healthcare AI.