Role Overview
Agents Only Technologies Inc. is seeking experienced Utilization Management (UM) Nurses, Physicians, and Clinical Documentation Professionals to support a specialized Prior Authorization and Appeals Preparation project.
This companion role focuses on the evidence-gathering, clinical documentation, and appeals side of utilization management. Contributors will develop realistic scenarios requiring the assembly of prior-authorization evidence packets and create gold-standard physician appeal letters when requests have been denied.
Unlike traditional Approve/Deny/Request More Information review, this role emphasizes persuasive, evidence-backed clinical writing, medical-necessity reasoning, policy interpretation, and appropriate use of supporting clinical literature.
This is a Priority 1 project with contributors expected to participate in iterative evaluation and calibration activities.
Key Responsibilities
As a Prior Auth and Appeals Prep – UM Nurse / Physician Reviewer, you will:
- Author realistic scenarios requiring assembly of prior-authorization packets using evidence from patient charts and clinical documentation.
- Identify and organize relevant clinical evidence needed to support a prior-authorization request.
- Draft gold-standard physician appeal letters addressing medical-necessity denials.
- Develop evidence-backed clinical arguments aligned with applicable CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and other relevant coverage criteria.
- Research and cite relevant peer-reviewed medical literature, including sources available through PubMed, to support clinical appeal arguments.
- Ensure cited literature is relevant, appropriately current, and directly supports the specific clinical argument or denial being addressed.
- Build evaluation rubrics assessing the completeness and relevance of evidence packets.
- Develop evaluation criteria for the accuracy, clinical reasoning, evidence support, and persuasiveness of appeal letters.
- Evaluate whether supporting documentation adequately addresses the stated reason for denial.
- Participate in iterative evaluation, calibration, and quality-review rounds.
- Apply consistent clinical documentation and evidence-review standards across assigned scenarios.
- Follow project guidelines, confidentiality requirements, and quality expectations.
Required Qualifications
Candidates should have:
- RN, MD/DO, or relevant clinical documentation professional credentials or professional experience.
- 3+ years of experience in prior authorization, utilization review, utilization management, clinical documentation, denials management, appeals, or a closely related healthcare function.
- Working knowledge of CMS NCD/LCD medical-necessity standards.
- Experience interpreting clinical documentation and identifying evidence relevant to medical-necessity determinations.
- Ability to research and cite peer-reviewed medical literature, including PubMed resources, to support clinical arguments.
- Strong persuasive medical and clinical writing skills.
- Strong analytical skills and attention to detail.
- Ability to independently evaluate evidence and construct logically supported clinical arguments.
- Ability to work remotely and independently while meeting project quality and turnaround expectations.
Preferred Qualifications
The following experience is preferred:
- Experience drafting actual payer appeal letters.
- Previous experience working in a denials and appeals department.
- Experience with prior-authorization appeals or reconsideration processes.
- Familiarity with structured literature searches and evidence grading.
- Experience evaluating the strength and applicability of clinical evidence.
- Experience with clinical content authoring, healthcare quality review, or evidence-based documentation.
- Experience supporting healthcare data, clinical evaluation, or AI/ML projects.
Preferred Qualifications
- Strong English written and verbal communication skills.
- Customer service, customer-experience, or contact-center experience is preferred.
- Comfort assisting customers with tax-preparation-related and account inquiries within established support guidelines.
- Strong attention to detail and ability to follow documented processes consistently.
- Good problem-solving, active-listening, and customer-service skills.
- Comfort navigating multiple systems, applications, and digital tools.
- Ability to communicate complex information clearly and in an easy-to-understand manner.
- Professional approach to handling confidential and sensitive customer information.
- Ability to work independently in a remote environment.
- Reliable internet connection and a suitable remote-work setup.
- Availability to meet the required schedule throughout the seasonal project.
Education / Expertise
Candidates with educational or professional backgrounds in one or more of the following areas are encouraged to apply:
- Nursing
- Medicine
- Utilization Management
- Utilization Review
- Clinical Documentation
- Health Information Management
- Clinical Appeals
- Denials Management
- Medical Necessity Review
- Case Management
- Healthcare Administration
Equivalent professional experience may also be considered where appropriate.
Job Details
- Type: Independent Contractor
- Markets: India | Philippines | United States
- Priority: Priority 1
- Start Date: Immediate joiners preferred
- Openings: Limited
- Schedule: Project-based; availability may vary based on workload and evaluation cycles
Important Notes
- Contributors must be comfortable working with detailed clinical documentation and evidence-based medical writing.
- Citations must be relevant to the specific clinical argument and denial being addressed.
- Contributors should be able to distinguish between evidence that is merely related to a condition and evidence that directly supports the clinical argument being made.
- Work may involve complex clinical scenarios requiring careful interpretation of patient records, coverage policies, and medical literature.
- Contributors may be required to participate in multiple evaluation and calibration rounds.
- Project access and task availability are subject to client requirements and business needs.
- All work must meet applicable quality, confidentiality, and project compliance requirements.
Work Arrangement
- Location: Remote
- Work Type: Independent Contractor
- Schedule: Project-based / Flexible, subject to project requirements
- Scope: India | Philippines | United States
Compensation
Actual earnings may vary based on task availability, productivity, quality performance, project requirements, certifications, domain expertise, and business needs.
How to Apply
Interested professionals may submit their application through the official application form.
Complete the application form
Please ensure your profile accurately reflects your clinical credentials, prior-authorization or appeals experience, relevant certifications, and areas of expertise. Only shortlisted candidates will be contacted.
Equal Opportunity
Agents Only Technologies Inc. is committed to fostering an inclusive and diverse global community. We welcome talented individuals from a wide range of backgrounds, experiences, and perspectives. Opportunities are made available based on qualifications, skills, experience, and business needs, with the goal of building a collaborative environment where contributors can learn, grow, and succeed together.
