Role Overview
Agents Only Technologies Inc. is seeking experienced Utilization Management (UM) Nurses and Physician Reviewers to support a specialized prior-authorization review project.
In this role, you will apply real-world utilization-management judgment to author clinical scenarios and evaluation criteria used to assess whether procedure and medication requests should be Approved, Denied, or returned for More Information. Contributors will work with cases spanning multiple clinical specialties and apply applicable CMS coverage policies and medical-necessity standards.
This is a Priority 1 project, and contributors should be prepared to participate in iterative review and evaluation activities across multiple testing rounds.
Key Responsibilities
As a Prior Auth Review – Utilization Management (UM) Nurse / Physician Reviewer, you will:
- As a Prior Auth Review – Utilization Management (UM) Nurse / Physician Reviewer, you will:
- Author realistic prior-authorization scenarios covering routine, complex, and safety-critical cases.
- Develop scenarios across specialties including radiology, surgery, cardiology, behavioral health, sleep studies, radiation therapy, spine/orthopedics, and durable medical equipment (DME).
- Create gold-standard three-way recommendations: Approve, Deny, or Request More Information.
- Apply CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and applicable medical-necessity standards when developing recommendations.
- Develop evaluation rubrics that assess whether a reviewer correctly applies clinical criteria and identifies the applicable coverage policy.
- Model appropriate Request More Information decisions when documentation is insufficient to support an approval or denial.
- Evaluate clinical reasoning, policy application, and documentation sufficiency across assigned scenarios.
- Participate in iterative evaluation and calibration reviews across multiple testing rounds.
- Maintain consistency, clinical accuracy, and appropriate documentation standards throughout assigned work.
- Follow project guidelines, quality requirements, and confidentiality expectations.
Required Qualifications
Candidates should have:
- An active RN license or MD/DO license appropriate to the applicable market.
- 3+ years of professional experience in utilization management, utilization review, case management, payer-side medical review, or a closely related function
- Direct working knowledge of CMS NCD/LCD coverage determinations and medical-necessity review standards.
- Experience reviewing clinical documentation and determining whether submitted information supports medical necessity.
- Comfort evaluating cases across multiple clinical specialties.
- Strong clinical judgment and attention to detail.
- Ability to independently interpret clinical documentation, coverage policies, and review criteria.
- Strong written communication and documentation skills.
- 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
- Case Management
- Clinical Documentation
- Health Information Management
- Healthcare Administration
- Payer-Side Medical Review
- Clinical Appeals
- Medical Necessity Review
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 testing cycles
Important Notes
- Active professional licensure is required for applicable clinical roles.
- Contributors must be able to independently review clinical documentation and apply relevant medical-necessity standards.
- Strong familiarity with CMS NCD/LCD policies is required.
- Work may involve complex or safety-critical clinical scenarios.
- Contributors may be required to participate in multiple evaluation and calibration rounds.
- Project access, task availability, and continuation are subject to client requirements and business needs.
- All submitted 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, utilization-management experience, relevant certifications, and areas of specialty. 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.
