Prior Authorization Specialist - A355

Pearl

4d • Remote

About The Position

Our client is a fast-growing healthcare operations company modernizing ophthalmology Revenue Cycle Management (RCM). They focus on improving prior authorization workflows, reducing administrative burden for provider practices, and leveraging technology and automation to streamline complex insurance approval processes. The company operates at the intersection of healthcare operations and software innovation, building systems that improve patient access to critical procedures.

We are seeking a highly experienced Prior Authorization Specialist to support complex ophthalmology cases within a high-growth healthcare operations environment. This role functions as a clinical escalation expert, handling high-complexity insurance authorizations, appeals, and medical necessity reviews for surgical and specialty procedures. You will serve as a key link between clinical workflows, US-based provider practices, and internal product/engineering teams, helping translate real-world authorization challenges into scalable system improvements.

This is not a traditional back-office role—this is a high-ownership, problem-solving position where you will actively shape workflows and automation design. The ideal candidate thrives in ambiguous, fast-moving environments, has deep expertise in US payer systems, and is comfortable making judgment calls on complex clinical documentation requirements.

Requirements

• 5+ years of experience in US Healthcare RCM, specifically Prior Authorization.
• Strong experience handling complex specialty cases (ophthalmology, oncology, or surgical specialties preferred).
• Deep understanding of US payer systems, insurance workflows, and medical necessity requirements.
• Experience working with CPT, ICD-10 coding and clinical documentation review.
• Excellent written and verbal English communication skills.
• Ability to work independently in fast-paced, ambiguous environments.

Nice To Haves

• Experience in ophthalmology prior authorization workflows.
• Background in startup or early-stage healthcare operations environments.
• Experience collaborating with product or engineering teams on workflow design.
• Familiarity with denial management and appeals strategy at scale.

Responsibilities

• Manage end-to-end prior authorization processes for complex ophthalmology procedures.
• Review clinical documentation to ensure medical necessity compliance (e.g., imaging, test results, physician notes).
• Submit and manage appeals, reconsiderations, and payer follow-ups for denied cases.
• Act as escalation point for complex authorization cases from junior eligibility staff.
• Conduct case audits to identify errors, gaps, and training opportunities.
• Develop and maintain internal payer and policy knowledge documentation.
• Collaborate with US-based product and engineering teams to map authorization workflows.
• Identify automation opportunities and define logic for system improvements.
• Report workflow failures, edge cases, and payer-specific exceptions.
• Communicate with US provider offices to resolve missing documentation issues.
• Coordinate across teams to ensure timely case resolution.
• Participate in daily operational standups and SLA monitoring discussions.

Benefits

• Competitive Salary: Based on experience and skills
• Remote Work: Fully remote—work from anywhere
• Team Incentives: Recognition for maintaining 100% CRM hygiene and on-time reporting
• Generous PTO: In accordance with company policy
• Health Coverage for PH-based talents: HMO coverage after 3 months for full-time employees
• Direct Mentorship: Guidance from international industry experts
• Learning & Development: Ongoing access to resources for professional growth
• Global Networking: Connect with professionals worldwide

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed