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.

Sponsorship, in any form, is not available for this position.

Location: Remote, US

Why you want to work on this team:

• 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.

Education and Experience:

• 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.

You will set yourself apart:

• 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.

What you will be doing:

• 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.

Availity culture and benefits:

• Availity is a certified “Great Place to Work”, a “Best Workplaces for Technology Companies”, a “Best Workplaces for Women” and a “Best Workplaces for Millennials”!
• Culture is important to us and there are many ways for you to make your mark here!
• We have several Diversity & Inclusion teams and various ways to engage with fellow Availity associates. “AvaiLadies”, “Beyond Black”, “HOLA”, “Availity Pride”, “VetAvaility” a Young Professionals Group and “She Can Code IT” a group for women in tech are some of the groups you can get involved in.
• Availity is a culture of continuous learning. We have many resources and experts in our tech stack and in our industry that can help get you there too!
• We offer a competitive salary, bonus structure, generous HSA company contribution, healthcare, vision, dental benefits and a 401k match program that you can take advantage of on day one!
• We offer 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.
• Interested in wellness? We allow our associates to reimburse up to $250/year for gym memberships, participation in racing events, weight management programs, etc.
• Interested in furthering your education? We offer education reimbursement!
• Availity offers Paid Parental Leave for both moms and dads, both birth parents and adoptive parents.
• Want to work for an organization that gives back to the community? You’re at the right place! Availity partners with various organizations, both locally and nationally, to raise awareness, funds and morale as our staff members volunteer their time and funds to engage the organizations campaign.

Next steps:

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.

Interview 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.