Infusions & Specialty Pharmacy Documentation & Criteria Reviewer

Hands-on infusions/SP experience in roles such as intake, documentation review, case management, and clinical review Confident identifying when documentation meets or fails to meet payer requirements Comfortable reviewing insurance coverage policies and applying them to real-world cases Highly organized, detail-focused, and confident making policy-based decisions Works well independently and values open communication within a remote team setting 4+ years working in infusions/SP, ideally in intake, documentation review, case management, and clinical review (preferred) Tech-savvy and comfortable using AI tools (preferred) Familiarity with Medicare, Medicaid, and commercial payer guidelines for infusions/SP (preferred) Understanding of HCPCS codes, NDCs, and common infusions/SP drug categories (preferred) Experience with audits, prior authorizations, and appeals is a strong plus (preferred) Familiarity with decision logic or rules-based platforms is helpful but not required (preferred)

Review the model’s outputs to improve criteria determinations Flag incorrect determinations, including false positives, false negatives, and unclear logic, with structured feedback Compare documentation against Medicare, Medicaid, and commercial payer coverage policies Analyze source materials (insurance policies, LCDs, etc.) to help validate qualification logic Work closely with internal teams to refine prompting logic and improve documentation review standards Maintain clear documentation of findings and contribute to process improvements