Availity is seeking a UM Nurse Analyst (Clinical Informaticist) to support its Auth AI solution. This role interprets payer medical policy guidelines and builds and maintains AI-enabled decision trees that reflect medical necessity criteria.
The position focuses on translating health plan medical policies into structured decision pathways, validating clinical alignment, and supporting implementation and ongoing maintenance of automated prior authorization workflows.
The role works cross-functionally with Product, Engineering, Medical Directors, and other clinical informatics teams to ensure decision logic remains clinically accurate, scalable, auditable, and aligned with payer policies.
This is a remote, U.S.-based position.
Education and experience
- Bachelor’s degree in nursing
- 3+ years of experience in a utilization management program with an insurer or healthcare provider, or equivalent clinical experience with familiarity in prior authorization submission practices
Required qualifications
- Strong understanding of medical necessity criteria, payer medical policy structure, prior authorization workflows, and utilization management principles
- Working knowledge of CPT, HCPCS, ICD-10, diagnosis, procedure, and documentation requirements
- Ability to interpret medical records and identify how physicians document conditions and findings
- Ability to identify policy ambiguities, edge cases, and workflow challenges impacting automated decision-making
- Strong communication skills for clinical, technical, operational, and customer-facing stakeholders
- Comfortable using technology and learning new applications
Preferred experience
- Experience reviewing and applying MCG, InterQual, or similar medical necessity criteria
Benefits and perks
- Competitive salary
- Bonus structure
- Generous HSA company contribution
- Medical, vision, and dental benefits
- 401(k) match available on day one
- Unlimited PTO for salaried associates
- 19 days of PTO for hourly associates, plus paid holidays
- Up to $250/year wellness reimbursement
- Education reimbursement
- Paid parental leave
- Remote-first work environment
Location
N/A
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
2 months ago