Prior Authorisation Manager - Clinical Expert

Mercor; San Francisco (CA); On-site; USD 150,000 - 190,000; Full time

Job summary

Mercor is partnering with a leading AI research lab to enhance AI-driven prior authorisation workflows for medical services. We are seeking experienced Prior Authorisation Managers with clinical expertise to train AI systems on medical-necessity criteria and payer review processes to reduce administrative burden and improve patient access.

Respondents will manage end-to-end authorisation workflows, review clinical documentation against criteria such as InterQual or MCG, coordinate with

Qualifications

• 5+ years of experience in prior authorisation or utilisation management, with at least 2 years in a management role.
• Strong clinical background with knowledge of medical necessity criteria.
• Experience with commercial, Medicare Advantage, and Medicaid authorisation requirements.

Responsibilities

• Manage end-to-end prior authorisation workflows for medical and clinical services across multiple payer types.
• Review clinical documentation against InterQual, MCG, or payer criteria.
• Evaluate AI-generated recommendations 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

Prior authorization management

Clinical review

Utilisation management

Stakeholder collaboration

Quality & detail orientation

English communication

Education

RN license

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.