Prior Authorization Specialist - A355

Industry

Healthcare / HealthTech / Revenue Cycle Management (RCM)

Work Arrangement

Remote

Job Type

Full-Time

Work Schedule

Shift aligned with US EST/PST (to support US provider practices)

Locations

Remote – Global (must overlap with US working hours)

About Pearl Talent

Pearl works with the top 1% of candidates from around the world and connects them with the best startups in the US and EU. Our clients have raised over $5B in aggregate and are backed by companies like OpenAI, a16z, and Founders Fund. They’re looking for the sharpest, hungriest candidates who they can consistently promote and work with over many years. Candidates we’ve hired have been flown out to the US and EU to work with their clients, and even promoted to roles that match folks onshore in the US.

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Why Work with Us?
At Pearl, we’re not just another recruiting firm—we connect you with exceptional opportunities to work alongside visionary US and EU founders. Our focus is on placing you in roles where you can grow, be challenged, and build long-term, meaningful careers.

About the Company

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.

Role Overview

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.

Your Impact:

• You will ensure timely and accurate approvals for high-complexity ophthalmology procedures, directly impacting patient access to care.
• You will reduce authorization delays and denial rates by strengthening documentation quality and review processes.
• You will help identify automation opportunities that improve operational efficiency and reduce manual workload across the RCM function.
• You will contribute to continuous workflow improvement by translating real payer behavior into scalable process logic.
• You will elevate team quality by mentoring junior staff and establishing best practices for complex case handling.

Core Responsibilities

Advanced Authorization Case Management – 40%

• 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.

Clinical QA & Team Escalation Support – 25%

• 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.

Workflow Optimization & Product Collaboration – 20%

• 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.

Stakeholder & Provider Coordination – 15%

• 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.

Requirements:
Must-Haves (Required)

• 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 (Preferred)

• 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.

Tools Proficiency

Must-Haves

• Payer Portals (e.g., Availity, Optum, Medicare/Medicaid portals)
• EMR/EHR systems (various provider systems)
• Google Workspace (Docs, Sheets, Gmail)
• Communication tools (Slack, Zoom)

Nice-to-Haves

• Automation or workflow tools (Zapier or similar)
• Project management tools (Asana, Trello, Notion)
• Data tracking or reporting dashboards

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

Our Recruitment Process

• Application
• Screening
• Skills Assessment
• Top-grading Interview
• Client Interview
• Job Offer
• Client Onboarding

Ready to Join Us?

If this role aligns with your skills and goals, apply now to take the next step in your journey with Pearl.