UM Nurse Analyst (Clinical Informaticist)

About the Role

The position of UM Nurse Analyst (Clinical Informaticist) reports 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 structured decision pathways, validates clinical alignment of decision logic, and supports implementation and maintenance activities related to automated prior authorization workflows.

Responsibilities

• 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.

Qualifications

• Bachelor's degree in nursing.
• At least 3+ years of experience in a 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.

Preferred Qualifications

• Experience reviewing and applying MCG, InterQual, or similar medical necessity criteria preferred.
• Exceptional critical thinking and reasoning skills.
• Ability to synthesize complex, abstract problems, and collaborate effectively with team members with diverse skillsets to create solutions.
• Self-motivated and a quick learner with an ability to multi-task.

Benefits

• Competitive salary and bonus structure.
• Generous HSA company contribution.
• Healthcare, vision, and dental benefits.
• 401k match program available on day one.
• Unlimited PTO for salaried associates + 9 paid holidays.
• Hourly associates start at 19 days of PTO and go up from there with all the same holiday benefits.
• $250/year reimbursement for gym memberships, participation in racing events, weight management programs, etc.
• Education reimbursement.
• Paid Parental Leave for both parents (birth and adoptive).

Schedule & Location

Remote, US.