About The Position
You are the clinical source of truth for how Penguin Ai turns health plan UM and medical policy text into structured, machine‑readable logic. This is not chart review - you validate the AI’s decomposition of policies into discrete questions, answers, decision points, and data facts so our UM Agent Suite can act reliably and audibly at scale. Your judgment is the gateway between narrative policy and production logic.
Requirements
- Active, unrestricted RN license in the United States (compact license preferred)
- Minimum 5 years clinical nursing experience, with ≥2 years in utilization management, medical policy interpretation, appeals/grievances, or policy development at a health plan or UM vendor
- Demonstrated fluency reading and applying health plan medical policies, coverage determinations, and national criteria (InterQual, MCG, CMS NCDs/LCDs)
- Strong analytical/logical reasoning - able to decompose narrative policy into discrete, testable decision points without losing nuance
- Precise written communication - able to document persuasive, defensible clinical rationale. Comfortable in structured, software‑based review environments and providing clear feedback on AI output
Nice To Haves
- BSN or MSN
- Background in clinical informatics, structured data, ontologies, or terminology standards (SNOMED CT, ICD‑10, CPT, LOINC)
- Prior exposure to AI/ML‑assisted clinical workflows, CDS, or ambient documentation tools
- Familiarity with URAC AI in Healthcare Accreditation, CMS‑0057‑F, or NCQA UM frameworks
- Prior experience at a health plan, UM/PA vendor, or healthcare technology company at payer scale
Responsibilities
- Validate AI policy decompositions: Confirm that AI‑generated questions, answers, decision points, and data facts reflect the clinical intent, scope, inclusions/exclusions, and decision logic of source policies
- Surface clinical nuance: Identify comorbidities, contraindications, sequencing, timing windows, documentation thresholds, edge cases, ambiguous language, and latent assumptions the AI may miss
- Approve, edit, or reject: Take definitive clinical positions in PolicyVault™ and related tooling; rewrite items to be unambiguous and answerable from typical documentation
- Document durable rationale: Produce concise, audit‑grade explanations for every validation decision to support URAC/CMS transparency and payer audits
- Close the loop with product & engineering: Partner to convert recurring patterns into upstream fixes in prompting, taxonomy, and validation workflows
- Keep the source of truth current: Track updates to client policies, InterQual/MCG, CMS NCDs/LCDs, and specialty guidelines; ensure structured representations remain aligned
- Raise the clinical bar: Build playbooks, validation standards, and onboarding materials for future policy reviewers
Benefits
- Medical, vision, and dental coverage
- Generous vacation policy and company holidays
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
