Prior Authorization Specialist (Healthcare)

TL;DR

Prior Authorization Specialist (Healthcare/RCM): Managing high-complexity insurance authorizations and medical necessity reviews for ophthalmology procedures with an accent on clinical escalation and payer system navigation. Focus on reducing denial rates and collaborating with product teams to automate authorization workflows.

Location: Remote (Global). Must overlap with US working hours (EST/PST)

Company

A fast-growing healthcare operations company modernizing ophthalmology Revenue Cycle Management (RCM) through technology and automation.

What you will do

• Manage end-to-end prior authorization for complex ophthalmology cases.
• Review clinical documentation to ensure compliance with medical necessity.
• Handle appeals, reconsiderations, and payer follow-ups for denied cases.
• Serve as the escalation point for junior staff and conduct case audits.
• Collaborate with product and engineering teams to map workflows and identify automation opportunities.
• Coordinate with US provider offices to resolve documentation gaps.

Requirements

• 5+ years of experience in US Healthcare RCM, specifically Prior Authorization.
• Experience with complex specialty cases (ophthalmology, oncology, or surgical).
• Deep knowledge of US payer systems and medical necessity requirements.
• Proficiency with CPT and ICD-10 coding.
• Excellent written and verbal English communication skills.
• Ability to align work schedule with US EST/PST time zones.

Nice to have

• Experience in ophthalmology-specific workflows.
• Background in early-stage healthcare startups.
• Experience in denial management and appeals strategy.

Culture & Benefits

• Fully remote work arrangement ("work from anywhere").
• Competitive salary based on experience.
• Generous PTO in accordance with company policy.
• HMO coverage for Philippines-based employees after 3 months.
• Direct mentorship from international industry experts.

Hiring process

• Initial screening and skills assessment.
• Top-grading and client interviews.
• Job offer and onboarding.