Senior Consultant Prior-Authorization & Appeals Specialist

Job 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. • 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