Infusions & Specialty Pharmacy Documentation and Criteria Reviewer

Infusions & Specialty Pharmacy Documentation and Criteria Reviewer – Remote

Overview

Join a fast-growing healthcare technology company transforming the referral and authorization process across the U.S. healthcare system. This fully remote opportunity is ideal for experienced infusion and specialty pharmacy professionals who thrive in documentation review, payer criteria analysis, prior authorizations, and clinical operations.

In this role, you will leverage your hands-on infusion/SP experience to review clinical documentation, evaluate authorization determinations, and ensure payer criteria are applied accurately and consistently. You’ll collaborate with cross-functional teams to improve documentation logic, reduce denials, and support faster patient access to care.

Key Responsibilities

• Review model-generated authorization and clinical review outcomes for accuracy and compliance


• Identify and flag incorrect determinations, including false positives, false negatives, and unclear decision logic


• Compare patient documentation against Medicare, Medicaid, and commercial payer coverage criteria


• Analyze payer policies, LCDs, and clinical guidelines to validate medical necessity and qualification requirements


• Provide structured feedback to improve documentation review workflows and decision logic


• Collaborate with internal operational and technical teams to refine processes and improve accuracy


• Maintain detailed documentation of findings and contribute to ongoing quality improvement initiatives

Qualifications

Required

• Hands-on experience within 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

Preferred

• 4+ years of Infusions/SP experience


• Experience with prior authorizations, audits, denials, and appeals processes


• Familiarity with HCPCS codes, NDCs, and specialty infusion drug categories


• Knowledge of payer guidelines across therapeutic areas such as neurology, immunology, and inflammatory conditions


• Comfortable using technology and AI-driven tools to improve workflow efficiency


• Experience working with decision logic or rules-based systems is a plus

Compensation & Benefits

• Salary: $55,000 – $57,000 annually


• Bonus eligibility and equity opportunities


• Fully remote flexibility


• Unlimited PTO


• 100% employer-paid employee health benefit options


• Employer-funded 401(k) match


• Competitive parental leave benefits

Why Join This Team?

• Be part of a mission-driven organization focused on reducing delays in patient care


• Work alongside a collaborative, innovative, and high-performing remote team


• Help improve healthcare access by ensuring referrals and authorizations are processed accurately and efficiently


• Gain exposure to cutting-edge healthcare technology and AI-supported operational workflows