{"@context":"https://schema.org","@type":"JobPosting","title":"Senior Consultant – Prior-Authorization & Appeals Specialist","description":"

We are seeking a Prior-Authorization & Appeals Specialist to build and operate an evidence-cited appeals capability that converts denied prior-authorizations and coverage decisions into recoverable revenue across both the medical and pharmacy benefit. This is a consulting/on-demand role supporting client engagements, with a strong emphasis on productizing the appeals process for repeatable use. The ideal candidate should be comfortable working directly from payer denial letters and patient records to build a defensible, tailored appeal.

Roles and Responsibilities

Review denied prior-authorization and coverage decisions against payer/plan coverage and formulary criteria
Extract and match supporting clinical facts from the patient record (EHR-driven) to plan criteria and published literature/compendia
Draft tailored medical-necessity and exception letters — formulary, step-therapy, and tiering exceptions for drugs; procedure and claim-denial appeals for devices
Route appeals through the appropriate payer appeal levels and track outcomes
Build and maintain template and coverage-criteria libraries to productize the appeals workflow
Ensure all appeals work stays within compliance guardrails (HIPAA and payer-specific rules)
Collaborate with clinical, regulatory, and coding colleagues to strengthen appeal arguments
Train internal team members on appeals methodology and payer-criteria interpretation

","datePosted":"2026-07-16T00:00:00.000Z","validThrough":"2026-09-14T00:00:00.000Z","employmentType":"FULL_TIME","identifier":{"@type":"PropertyValue","name":"myjobb-ai","value":"5998962"},"url":"https://myjobb.ai/jobs/senior-consultant-prior-authorization-appeals-specialist/5998962","directApply":false,"hiringOrganization":{"@type":"Organization","name":"CapeStart","logo":"https://static.ambitionbox.com/assets/v2/images/rs:fit:200:200:false:false/aHR0cHM6Ly9tZWRpYS5uYXVrcmkuY29tL21lZGlhL2FiY29tcGxvZ28vY2FwZXN0YXJ0LmpwZw.webp","sameAs":"https://www.capestart.com/"},"jobLocation":[{"@type":"Place","address":{"@type":"PostalAddress","addressLocality":"Remote","addressRegion":"Remote","addressCountry":"India"}}]}