Infusions & Specialty Pharmacy Documentation and Criteria Reviewer

About the role

This fully remote position is with a fast‑growing healthcare technology company that streamlines referral and authorization processes across the U.S. healthcare system. You will use your infusion and specialty pharmacy expertise to review clinical documentation, validate payer criteria, and help accelerate patient access to care.

Key responsibilities

• Review model‑generated authorization and clinical outcomes for accuracy and compliance.
• Identify and flag incorrect determinations, including false positives, false negatives, and ambiguous decision logic.
• Compare patient documentation against Medicare, Medicaid, and commercial payer coverage criteria.
• Analyze payer policies, LCDs, and clinical guidelines to confirm medical necessity.
• Provide structured feedback to improve documentation review workflows and decision logic.
• Collaborate with internal operational and technical teams to refine processes and boost accuracy.
• Maintain detailed documentation of findings and support ongoing quality‑improvement initiatives.

Required profile

• Hands‑on experience in Infusions and/or Specialty Pharmacy operations.
• Background in intake, documentation review, case management, clinical review, authorizations, audits, or appeals.
• Strong understanding of payer requirements and medical‑necessity documentation.
• Experience reviewing Medicare, Medicaid, and commercial insurance coverage policies.
• Highly detail‑oriented with strong analytical and organizational skills.
• Ability to work independently in a fully remote environment while maintaining strong communication.

Required skills

• Familiarity with HCPCS codes.
• Familiarity with National Drug Codes (NDCs).
• Comfort using AI‑driven tools to improve workflow efficiency.
• Experience with decision‑logic or rules‑based systems.

What we offer

• Salary range $55,000 – $57,000 annually.
• Bonus eligibility and equity opportunities.
• Fully remote flexibility.
• Unlimited PTO.
• 100% employer‑paid health benefit options.
• Employer‑funded 401(k) match.
• Competitive parental leave benefits.