Role: SME Prior Authorization (PA)
Exp: 10+yrs
Location: NYC, NY (Only local)
Job Summary
The Senior Business & Technology SME role is a strategic position dedicated to modernizing the Prior Authorization (PA) ecosystem. The candidate will lead the design of disruptive AI solutions—such as Generative AI and LLMs—while optimizing organizational performance, reducing denial rates, and ensuring compliance with healthcare regulations and interoperability standards.
Role Responsibilities
The primary focus is to:
Drive digital transformation and operational optimization within the Prior Authorization ecosystem.
Implement AI-driven workflows (e.g., automated clinical decision engines) to maximize efficiency and decrease turnaround times.
Bridge the gap between business strategy, clinical workflows, and advanced technology architectures.
Required Experience
1. Domain & Business Expertise
Minimum 10 years of healthcare industry experience.
At least 7 years focused specifically on:
Prior Authorization operations
Utilization Management
ePA (Electronic Prior Authorization) platform engineering
In-depth knowledge of:
CMS/state regulations
CAQH CORE rules
Healthcare coding frameworks:
CPT
HCPCS
ICD-10
NDC
2. AI & Technical Competency
Proven experience deploying AI architectures in clinical environments, including:
Generative AI
LLMs
NLP
OCR
Strong proficiency in:
HL7 FHIR standards
Da Vinci Implementation Guides, including:
CRD
DTR
PAS
EDI standards:
278
275
837
Experience with major EHR systems, such as:
Epic
Cerner
Athenahealth
3. Education & Certifications
Bachelor’s degree in a relevant field required.
Master’s degree preferred.
Highly desirable credentials include:
HL7 FHIR Certified Implementer
CPHIMS
AI/ML Architecture certifications
PMP
Contact Information
Email: balamuralid@kaizentek.com
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