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Role Description
This AI lab is seeking experienced professionals in the infusions and specialty pharmacy (SP) space to support their documentation and criteria review systems. The role ensures that payer authorization and medical necessity criteria are accurately applied to clinical documentation. You’ll be working closely with AI-generated outputs—validating determinations, reviewing against payer coverage policies, and providing structured feedback to refine decision-making standards. If you’ve worked in intake, case management, documentation review, or clinical review in infusions/SP, this is an opportunity to apply that expertise in a flexible, impactful way.
Responsibilities
- Review AI model outputs for accuracy in clinical criteria determinations
- Flag incorrect or unclear determinations with structured feedback
- Compare documentation against Medicare, Medicaid, and commercial payer coverage policies
- Analyze source materials (insurance policies, LCDs, etc.) to validate decision logic
- Collaborate with AI and product teams to refine workflows and review standards
- Maintain clear records and contribute to process improvements
Qualifications
- Hands-on experience in infusions/SP (intake, documentation review, case management, or clinical review)
- Strong understanding of payer requirements and compliance standards
- Ability to interpret and apply insurance coverage policies to real-world cases
- Detail-oriented, highly organized, and confident in making policy-based decisions
- Comfortable working independently in a remote environment
- 4+ years of experience in infusions/SP (preferred)
- Familiarity with Medicare, Medicaid, and commercial payer guidelines (preferred)
- Knowledge of HCPCS codes, NDCs, and common infusion drug categories (neurology, immunology, etc.) (preferred)
- Experience with prior authorizations, audits, or appeals (preferred)
- Tech-savvy and comfortable using AI tools in workflows (preferred)
Benefits
- Flexible remote engagement (20–30 hrs/week)
- Apply your expertise in infusions/SP to cutting-edge AI systems
- Work with a global, high-caliber team through Mercor
- Contribute to a mission-driven project reducing patient delays and denials
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