UM Nurse Analyst (Clinical Informaticist)

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change.

The position of UM Nurse Analyst (Clinical Informaticist) will report to the Clinical Manager of Availity’s Auth AI solution. This position is responsible for the interpretation of payer medical policy guidelines and the construction and maintenance of AI-enabled decision trees that accurately reflect medical necessity criteria. The analyst translates health plan medical policies into structure decision pathways, validates clinical alignment of decision logic, and supports implementation and maintenance activities related to automated prior authorization workflows.

The role requires in-depth knowledge of utilization management principles, the role and purpose of medical necessity guidelines and prior authorization adjudication practices. This individual will work in a cross-functional environment and collaborate with Product, Engineering, Medical Directors and other clinical informatics teams to ensure decision tree logic remains clinically accurate, scalable, auditable, and aligned with payer medical policies. The successful candidate will be detail oriented with strong analytic reasoning skills, demonstrate strong communication and organizational skills while remaining open-minded, embracing change and the spirit of innovation.

• Dynamic, collaborative group working on innovative technologies to disrupt the status quo and solve the problem of prior authorization in healthcare.
• Opportunity to work directly on AI technology and its application to the healthcare industry.

• Bachelor’s degree in nursing.
• At least 3+ years of experience in an Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices.
• “Computer smart” – General power user of technology and confident with navigating new technologies and applications.
• Familiarity and understanding of interpreting medical records to be able to identify how physicians may document conditions and findings.
• Strong understanding of medical necessity criteria, payer medical policy structure, prior authorization workflows, and utilization management principles.
• Working familiarity with CPT, HCPCS, ICD-10, diagnosis, procedure, and documentation requirements.
• Ability to identify policy ambiguities, edge cases, and workflow challenges impacting automated decision-making.
• Ability to communicate clinical rationale clearly to technical, operational, and customer-facing stakeholders.
• Experience reviewing and applying MCG, InterQual, or similar medical necessity criteria preferred.

• If you have exceptional critical thinking and reasoning skills.
• If you can synthesize complex, abstract problems, and collaborate effectively with team members with diverse skillsets to create solutions.
• If you are self-motivated and a quick learner with an ability to multi-task.

• →Reviewing payer Medical Policy Guidelines to identify pertinent medical necessity criteria related to specific Procedural codes or CPT codes.
• →Build and maintain attestation questions, decision pathways, and recommendation logic that accurately reflect payer medical policy requirements and clinical intent.
• →Provide clinical guidance and support to Product Operations, Engineering and customer-facing teams (e.g. implementation, account executives) regarding decision tree behavior, policy interpretation, and clinical workflow considerations.
• →Review and incorporate payer medical policy updates into existing decision trees.
• →Support routine maintenance, change requests, and release readiness efforts.
• →Review audit findings, customer feedback, and implementation observations to identify opportunities for decision tree improvement.

After you apply, you will receive text/email messages thanking you for applying and then you will continue to receive more text/email messages alerting you as to where you are in the recruitment process.

• Manager resume review 
• Recruiter video interview
• Manager video interview
• Panel video interview
• Senior leadership video interview

Video Camera Usage:

Availity fosters a collaborative and open culture where communication and engagement are central to our success.  As a remote first company, we are also camera-first and provide all associates with camera/video capability to simulate the office environment. If you are not able to use your camera for all virtual meetings, you should not apply for this role.

Having cameras on helps create a more connected, interactive, and productive environment, allowing teams to communicate more effectively and build stronger working relationships.  The usage of cameras also enhances security and protects sensitive company information. Video participation is required to ensure that only authorized personnel are present in meetings and to prevent unauthorized access, data breaches, preventing social engineering, or the sharing of confidential information with non-participants.

Availity is an equal opportunity employer and makes decisions in employment matters without regard to race, religious creed, color, age, sex, sexual orientation, gender identity, gender expression, genetic information, national origin, religion, marital status, medical condition, disability, military service, pregnancy, childbirth and related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.

Availity is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. When required by state law or federal regulation, Availity uses I-9, Employment Eligibility Verification in conjunction with E-Verify to determine employment eligibility. Learn more about E-Verify at http://www.dhs.gov/e-verify.

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