Domain expert for prior Authorization stream- 10+ yrs- NYC, NY- Onsite

The Senior Business & Technology SME role is a strategic position dedicated to modernizing the Prior Authorization (PA) ecosystem. The candidate will lead the design of disruptive AI solutions—such as Generative AI and LLMs—while optimizing organizational performance, reducing denial rates, and ensuring compliance with healthcare regulations and interoperability standards.

Role Review

The role is situated at the intersection of healthcare operations, regulatory mandates, and AI innovation. The primary focus is to:

• Drive digital transformation and operational optimization within the PA ecosystem.
   

• Implement AI-driven workflows (e.g., automated clinical decision engines) to maximize efficiency and decrease turnaround times.
   

• Bridge the gap between business strategy, clinical workflows, and advanced technology architectures.
   

Required Experience

• Domain & Business Expertise: Minimum 10 years of healthcare industry experience, with at least 7 years focused specifically on Prior Authorization operations, Utilization Management, or ePA platform engineering. In-depth knowledge of CMS/state regulations, CAQH CORE rules, and coding frameworks (CPT, HCPCS, ICD-10, NDC) is essential.
   

• AI & Technical Competency: Proven experience deploying AI architectures (GenAI, LLMs, NLP, OCR) in clinical environments. Strong proficiency in HL7 FHIR standards, Da Vinci Implementation Guides (CRD, DTR, PAS), EDI standards (278/275/837), and major EHR systems (Epic, Cerner, Athenahealth).
   

• Education & Certifications: Bachelor’s degree in a relevant field (Master’s preferred). Highly desirable credentials include HL7 FHIR Certified Implementer, CPHIMS, AI/ML architecture certifications, or PMP