Prior Authorization Representative Jobs

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Job Summary The Representative I is the initial point of contact for Prior Authorization requests from members, providers, and a diverse customer base. The Rep I will make the determination if a complex request should be transferred to a pharmacist for assistance. Additionally, the Rep I is responsible for maintaining complete, timely, and accurate documentation of all approvals and denials. In order to be successful in this role you will need proficiency pronouncing drug names and diagnosis and recognizing medical terminology. As well as navigating multiple software systems to document conversations and outcomes, which require keyboarding skills. This position requires schedule flexibility including rotations through nights, weekend and holiday coverage. Required Qualifications - 1 year experience in customer service or call center environment - Must be able to work from home - Have high speed internet Preferred Qualifications - Previous experience in pharmacy or healthcare industry. - Associate's or Bachelor's Degree. Pharmacy Technician License Education High School Diploma or equivalent GED Anticipated Weekly Hours 40 <p sty

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This position is for a Clinical Pharmacist working in the Prior Authorization team. - Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. - Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. - One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. - Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. - Establishes and maintains communicat

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary - Processes prior authorization requests received by phone, fax, or electronically and utilizes various computer resources, existing criteria, and medication guidelines to perform clinical research to support prior authorization reviews. - Proactively completes prior authorization approvals and denials that are due to expire and maintains complete, timely, and accurate documentation. - Reviews potential prior authorization denial language to ensure NCQA requirements are met. - Follows prior authorization workflow, policies, and procedures during the course of the workday. - Answers a potentially high volume of prior authorization inquiry calls from provider's offices, pharmacies, and internal partners and uses various computer resources to communicate prior authorization status or decisions. - Maintains a balance of productivity, quality and timeliness of work. - Participates in training and continuing education as required. - Participates in team/departmental meetings as required. - Excellent attendance is a must. - Successful pharmacy technicians will be proficient in drug name and diagnosis pronunciation, recognizing medical terminology, and navigating multiple computer resources to document conversations and prior authorization decisions. - Successful pharmacy technicians will possess good written and verbal communication

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Technician I is the initial point of contact for Prior Authorization requests from members, providers, and a diverse customer base. The Tech I will make the determination if a complex request should be transferred to a pharmacist for assistance. Additionally, the Tech I is responsible for maintaining complete, timely, and accurate documentation of all approvals and denials. In order to be successful in this role you will need proficiency pronouncing drug names and diagnosis and recognizing medical terminology. As well as navigating multiple software systems to document conversations and outcomes, which require keyboarding skills. This position requires schedule flexibility including rotations through nights, weekend and holiday coverage. Required Qualifications - 1 year experience in customer service or call center environment - Must be able to work from home - Have high speed internet Preferred Qualifications - Previous experience in pharmacy or healthcare industry. - Associate's or Bachelor's Degree. Pharmacy Technician License Education High School Diploma or equivalent GED Anticipated Weekly Hours 40<p style="text

Opportunity Overview: Cohere Health is at the forefront of leveraging artificial intelligence (AI) to transform prior authorization, shifting from transaction-based processes to creating elevated care journeys. By integrating AI into healthcare decisioning, we aim to improve efficiency, reduce costs, and ultimately enhance patient care. This is a unique opportunity to join our rapidly growing Clinical Intelligence team, where you’ll work on building impactful healthcare technologies that streamline and optimize the prior authorization process using AI/ML and Advanced Rules Engines. What you’ll do: Contribute to the functional & technical roadmap for the team, working alongside cross-functional teams to deliver high-impact deterministic rules-based and AI-driven healthcare automation solutions. Actively support the technical design process, bringing your expertise and analysis to help make data-driven decisions Continuously discover, understand, and implement new technologies & services to maximize development efficiency Contribute heavily to feature design, development, testing, and delivery of our cloud platform and web applications Support all parts of our platform from the database to the frontend Drive daily engineering release once 2-4 times a month Perform production support duties 1-2 times a year. ISMS roles and responsibilities: Good knowledge of Information practices. Assist the manager in all the information security activities implementation and maintenance process. Ensuring the team and imparted with Competence related to Information security Responsible for implementation of security policies and procedures and report any issues to the Information Security Manager. What we looking for: You have experience working on software development teams, building and deploying full stack web applications You are passionate about building quality products and want to own product development end-to-end, with excellent design and development stan

Opportunity Overview: Cohere Health is at the forefront of leveraging artificial intelligence (AI) to transform prior authorization, shifting from transaction-based processes to creating elevated care journeys. By integrating AI into healthcare decisioning, we aim to improve efficiency, reduce costs, and ultimately enhance patient care. This is a unique opportunity to join our rapidly growing Clinical Intelligence team, where you’ll work on building impactful healthcare technologies that streamline and optimize the prior authorization process using AI/ML and Advanced Rules Engines. What you’ll do: Contribute to the functional & technical roadmap for the team, working alongside cross-functional teams to deliver high-impact deterministic rules-based and AI-driven healthcare automation solutions. Actively support the technical design process, bringing your expertise and analysis to help make data-driven decisions Continuously discover, understand, and implement new technologies & services to maximize development efficiency Contribute heavily to feature design, development, testing, and delivery of our cloud platform and web applications Support all parts of our platform from the database to the frontend Drive daily engineering release once 2-4 times a month Perform production support duties 1-2 times a year. ISMS roles and responsibilities: Good knowledge of Information practices. Assist the manager in all the information security activities implementation and maintenance process. Ensuring the team and imparted with Competence related to Information security Responsible for implementation of security policies and procedures and report any issues to the Information Security Manager. What we looking for: You have experience working on software development teams, building and deploying full stack web applications You are passionate about building quality products and want to own product development end-to-end, with excellent design and development stan

Opportunity Overview: Cohere Health is at the forefront of leveraging artificial intelligence (AI) to transform prior authorization, shifting from transaction-based processes to creating elevated care journeys. By integrating AI into healthcare decisioning, we aim to improve efficiency, reduce costs, and ultimately enhance patient care. This is a unique opportunity to join our rapidly growing Clinical Intelligence team, where you’ll work on building impactful healthcare technologies that streamline and optimize the prior authorization process using AI/ML and Advanced Rules Engines. What you’ll do: Contribute to the functional & technical roadmap for the team, working alongside cross-functional teams to deliver high-impact deterministic rules-based and AI-driven healthcare automation solutions. Actively support the technical design process, bringing your expertise and analysis to help make data-driven decisions Continuously discover, understand, and implement new technologies & services to maximize development efficiency Contribute heavily to feature design, development, testing, and delivery of our cloud platform and web applications Support all parts of our platform from the database to the frontend Drive daily engineering release once 2-4 times a month Perform production support duties 1-2 times a year. ISMS roles and responsibilities: Good knowledge of Information practices. Assist the manager in all the information security activities implementation and maintenance process. Ensuring the team and imparted with Competence related to Information security Responsible for implementation of security policies and procedures and report any issues to the Information Security Manager. What we looking for: You have experience working on software development teams, building and deploying full stack web applications You are passionate about building quality products and want to own product development end-to-end, with excellent design and development stan

Opportunity overview The Learning & Development Specialist will work in support of the UM Service Operations Team at Cohere Health who conduct reviews and decision Prior Authorization requests for a patient’s medical insurance. You will implement training processes to improve staff performance and onboard new hire employees to the Cohere Operations teams, You will provide support to all functions within the Training & Quality department. With a solid foundation in Training, you are expected to be flexible and nimble in your role to manage short- and long-term projects as well as dealing with day-to-day tasks. What you’ll do: Facilitate training for the New Hire onboarding and continuous improvement of the Service Operations Staff Work with onshore teams to Develop and maintain Training materials Perform Quality Audit checks as required Coach team members for improvement Provide reporting on performance and key areas of Training Performance to Sr Leadership Lead and facilitate training programs for new-hire onboarding and ongoing development, ensuring Service Operations staff are fully prepared to meet performance, quality, and compliance expectations Design, develop, and continuously refine training materials, job aids, and workflow documentation to support new products, process changes, and organizational initiatives Conduct judgment-based quality audits across operational workflows, applying clinical and operational standards to evaluate accuracy, compliance, and readiness Provide targeted coaching and performance improvement guidance, using audit findings and behavioral insights to elevate competency, accuracy, and decision-making across teams Analyze training and quality data to identify trends, performance gaps, and opportunities, synthesizing insights into clear recommendations for senior leadership Build and deliver regular reporting on training outcomes, competency progression, audit results, and operational readiness, shaping leade

Opportunity Overview: We are seeking a Lead Software Engineer to join our Integrations team. In this role, you will be designing, developing, and scaling highly available healthcare integration systems supporting prior authorization workflows across providers, payers, and delegated entities. You'll direct a fast-paced, autonomous,agile team of software engineers in the design, development, and operational support of a growing enterprise integration platform. This is an opportunity to drive technical excellence at the intersection of healthcare interoperability and modern distributed systems. What you’ll do: Technical Leadership: Provide technical leadership across architecture, system design, platform scalability, reliability, and operational excellence. Platform Engineering: Design and build scalable, resilient, and high-performing systems that support critical business workflows and enterprise integrations. Integration Solutions: Lead the development and maintenance of secure integrations with internal and external platforms, partners, and third-party systems. Cloud & Automation: Drive cloud infrastructure, deployment automation, and software delivery practices that enable reliable and efficient releases. Distributed Systems: Design and support event-driven and distributed architectures that enable scalable and fault-tolerant processing. Operational Excellence: Establish monitoring, observability, and incident response practices to ensure system reliability, performance, and availability. Quality Engineering: Champion automated testing, quality assurance, and engineering best practices throughout the software development lifecycle. Production Support: Lead the resolution of complex production issues and drive continuous improvement in platform stability and operational efficiency. Cross-Functional Collaboration: Partner with product, operations, data, security, and business stakeholders to deliver solutions aligned with organizational goals. Agile Delive

Opportunity Overview: We are looking for a Senior Clinical Configuration Analyst to play a key role in the technical configuration of platform requirements for Cohere’s Platform-as-a-Service (PaaS) clients. Reporting into our Senior Manager, PaaS Value Delivery, you will be part of a small, fast-paced team working directly with client-facing team members to understand and deliver key clinical configurations that are integral to helping new and existing clients meet their prior authorization automation goals. Ultimately, the work you do will have a direct impact on the growth of the company and our ability to assist more patients at a time in their healthcare journey when they need help most. What you’ll do: Ensure thorough understanding of client’s technical requirements to facilitate seamless configuration of platform requirements during new client implementations Test configurability of new product functionality, or enhanced existing functionality, built to accommodate custom client requirements Define test scenarios and success criteria for all new and existing client platform configurations Execute on configuration of platform requirements in accordance with project timelines and client expectations Triage and resolve technical issues, during end-to-end testing or post-implementation, in a timely manner to ensure client satisfaction Serve as a technical SME for client-facing analysts during each stage of the customer lifecycle: providing education and answers to questions around configurability of client platform requirements; occasionally interfacing directly with clients to address issues Collaborate with Product, Development, Design, and Engineering to scope, develop, and implement internal configuration management tools that will help scale configuration work Required Qualifications: Must-haves 3-6 years of professional experience in a Configuration Management role; Bachelor’s degree in Computer Science, Systems Engineering, or related field Problem-Solving

Opportunity Overview: The Intake Specialist role is a key position supporting US healthcare operations by ensuring accurate and timely processing of patient and provider requests. In this role, you will support healthcare providers, internal clinical teams, and operations teams by collecting, reviewing, and processing information required for healthcare services and prior authorization workflows. As an Intake Specialist, you will manage healthcare requests received through multiple channels including phone, email, fax, and online platforms. You will be responsible for gathering required documentation, validating information, updating systems accurately, and ensuring requests are processed within defined turnaround times. This role requires strong communication skills, attention to detail, problem-solving ability, and the ability to work effectively in a fast-paced healthcare operations environment. What you’ll do: Provider/Customer Calling Support (Inbound & Outbound) Handle inbound and outbound calls with US healthcare providers and stakeholders. Process incoming healthcare requests received from US providers through Calls , fax, email, and electronic systems. Review medical documentation for completeness and accuracy. Validate required information needed for prior authorization and clinical review. Enter and update patient, provider, and request details accurately in healthcare systems. Identify missing information and coordinate with appropriate teams/providers for resolution. Maintain high standards of accuracy, quality, and productivity. Follow HIPAA guidelines and maintain confidentiality of patient information. Support process improvements and operational initiatives. Provide professional and timely support while addressing provider questions and requests. Document all interactions accurately in internal systems. Provide first-level resolution whenever possible. Escalate complex issues to appropriate teams. Maintain a customer-focused approach during ever

At Vanta, our mission is to help businesses earn and prove trust. We believe that security should be monitored and verified continuously, and we empower companies to practice better security and prove it with ease. Vanta has a kind and talented team, and while some have prior security experience, many have been successful at Vanta without it. Vanta for Government (V4G) is how we bring that mission to the public sector. As federal compliance undergoes its biggest shift in a decade — FedRAMP 20x, machine-readable authorization, OSCAL — we're building the platform that turns federal frameworks into automated, continuously monitored product experiences. The GRC Subject Matter Experts on this team are the people who make that possible. As Vanta's GRC Subject Matter Expert for V4G , you'll own federal compliance content used by every customer pursuing or maintaining federal authorization on our platform. This is an interpretation-and-authoring role, not a compliance program administration role: your job is to interpret underlying control requirements, identify where FedRAMP modifies or constrains the NIST framework, and translate those interpretations into precise, technically testable guidance that engineering can build and customers can act on. The content you write ships as product — a five-person startup and a Fortune 100 CSP both receive it — so calibrating depth, precision, and universality is the core craft. You'll join Vanta's Security organization, which directly influences product development, facilitates the creation of automated GRC solutions for customers, and provides expert advisory services across the company. What you’ll do as a V4G GRC SME at Vanta: Build and own federal compliance frameworks — Lead the creation, enhancement, and lifecycle management of controls, evidence requirements, and implementation guidance for FedRAMP (Low/Moderate/High), NIST SP 800-53, NIST SP 800-171, CMMC, DFARS, and StateRAMP. Author clear control rationales, acceptance crite

At Vanta, our mission is to help businesses earn and prove trust. We believe that security should be monitored and verified continuously, and we empower companies to practice better security and prove it with ease. Vanta has a kind and talented team, and while some have prior security experience, many have been successful at Vanta without it. Our Software Engineers build and own high-value products for our customers and the infrastructure that lets our business scale. Vanta's team and technology surface are growing quickly, and it's essential that we invest in the right abstractions and systems to scale with our business. As a Software Engineer, you'll build and own full-stack features and platform primitives across our stack, work closely with the teams and partners who depend on what you ship, and grow into broader technical ownership. Your work will directly accelerate Vanta's growth. Our business has found incredible product-market fit and has monetized effectively since the day we signed our first customer. We're growing at a blistering pace, which presents career-defining opportunities for engineers to accelerate their growth and to contribute to a rapidly-scaling company. Visit our Vanta Engineering Blog to learn more about what our team is working on! The Integrations Platform team within Vanta Government Cloud mission is to power the world's largest trust automation ecosystem, enabling any person or agent to build, connect, and automate trust seamlessly. Federal compliance is going through its biggest shift in a decade and this team builds the integration platform underneath Vanta Government Cloud that turns federal frameworks into automated, continuously monitored product experiences. This is a builder role: you'll turn federal control requirements into the platform primitives and integrations that make continuous authorization real. We own Vanta's integration ecosystem within the US Government Cloud, which currently includes a growing set of integrations

The MongoDB Atlas team is a diverse group of contributors working together to help our users manage MongoDB at global scale. We are responsible for MongoDB Atlas: our database as a service offering and fastest growing product which allows users to deploy fault-tolerant, globally distributed MongoDB clusters in just minutes. We're seeking a Senior Engineer to join the Atlas Identity and Access Management (IAM) team. IAM is a platform and a product team. We serve internal engineers by providing them a secure and durable suite of services, and we serve external customers by providing them user facing features and products. We are the owners of Atlas’ authentication (OAuth, SSO, Federated Identity) and authorization (RBAC, ABAC) systems, along with many others. The IAM team’s mission is to enable customers to securely build their applications with Atlas through our best in class user experience. We are looking to speak to candidates who are based in New York City, NY for our hybrid working model. Role Responsibilities Design, architect, build, and deliver core pieces of IAM Lead projects from specification to delivery Mentor and grow other team members Improve our codebase, best practices, and design principles Define your top priorities and focuses, communicate them, and execute against them Lead and contribute to complex technical projects and initiatives Candidate Profile 5+ years experience of software engineering, primarily focused on backend systems Proficient in a modern compiled programming language (Java, Go, C#, C++, etc.) Willingness to learn JavaScript and/or TypeScript along with modern frontend technologies (React, Redux, etc.); prior experience a plus Excellent communication skills, both written and verbal Desire to collaborate with colleagues and mentor fellow engineers Is curious, collaborative, empathetic, and intellectually honest Has a passion for problem solving and learning new things in the domains of computer science and software engineering Expe

The MongoDB Atlas team is a diverse group of contributors working together to help our users manage MongoDB at a global scale. We are responsible for MongoDB Atlas: our database-as-a-service offering and fastest-growing product, which allows users to deploy fault-tolerant, globally distributed MongoDB clusters in just minutes. We're seeking a Software Engineer to join the Atlas Identity and Access Management (IAM) team. The IAM team owns authentication and authorization for all of MongoDB Atlas, spanning from the underlying platform to user-facing features and products. IAM is both a platform and a product team, serving internal engineers as well as external customers. We enjoy the challenge of keeping MongoDB Atlas secure while providing a best-in-class user experience for users ranging from startup to enterprise. We are looking to speak to candidates who are based in New York City, NY for our hybrid working model. Role Responsibilities Lead medium-sized, full-stack projects from technical design to delivery Collaborate with colleagues at all stages of the project lifecycle (ideation, requirements gathering, design, execution, and delivery) Own our leadership principles , and exemplify them in your work Continue to learn and be curious in growing your career! Candidate Profile 2+ years of professional experience building full-stack web applications Proficient in a modern compiled programming language (Java, Go, C#, C++, etc.) Willingness to learn JavaScript and/or TypeScript along with modern frontend technologies (React, Redux, etc.); prior experience a plus Excellent communication skills, both written and verbal Is collaborative, empathetic, and intellectually honest Success Measures In 1 month, you’ll have shipped code into production In 3 months, you’ll have collaborated and delivered on a project with other engineers on the team In 6 months, you’ll have led the technical design, execution, and delivery of a project About MongoDB MongoDB is built for change, em