Documentation and Criteria Review Specialist (AI Training)

TL;DR

Documentation and Criteria Review Specialist (AI Training): Reviewing and validating model-generated medical authorization outcomes with an accent on clinical documentation and payer standards. Focus on identifying model errors, refining prompting logic, and ensuring alignment with Medicare, Medicaid, and commercial policies.

Location: Remote (Must be based in the USA)

Salary: $55K – $57K

Company

hirify.global is a health-tech company automating medical referral qualification using their proprietary RaeLM™ model to reduce patient delays across the U.S. healthcare system.

What you will do

• Review model outputs to improve criteria determinations for medical authorizations.
• Identify and flag false positives, false negatives, and logic errors with structured feedback.
• Validate qualification logic against Medicare, Medicaid, and commercial payer coverage policies.
• Analyze insurance policies and LCDs to refine model prompting logic.
• Collaborate with internal teams to improve documentation review standards.
• Maintain detailed documentation of findings to drive process improvements.

Requirements

• Hands-on experience in infusions/specialty pharmacy (intake, documentation review, or case management).
• Ability to determine if documentation meets specific payer requirements.
• Proficiency in reviewing and applying insurance coverage policies to real-world cases.
• Must be based in the USA to align with U.S. healthcare system requirements and benefits.
• High level of organization and detail-orientation for policy-based decision making.

Nice to have

• 4+ years of experience in infusions/SP.
• Experience using AI tools to improve accuracy and efficiency.
• Understanding of HCPCS codes, NDCs, and common infusion drug categories.
• Background in audits, prior authorizations, and appeals.
• Familiarity with decision logic or rules-based platforms.

Culture & Benefits

• Full-remote flexibility and unlimited PTO.
• 100% paid employee health benefit options.
• Employer-funded 401(k) match.
• Competitive parental leave.
• High-impact environment following the "Cowboy" value of ownership and pace.