𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗥𝗲𝘃𝗶𝗲𝘄 & 𝗠𝗲𝗱𝗶𝗰𝗮𝗹 𝗗𝗼𝗰𝘂𝗺𝗲𝗻𝘁𝗮𝘁𝗶𝗼𝗻 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁 Remote | Independent Contractor | United States 𝗔𝗯𝗼𝘂𝘁 𝗔𝗴𝗲𝗻𝘁𝘀 𝗢𝗻𝗹𝘆 𝗧𝗲𝗰𝗵𝗻𝗼𝗹𝗼𝗴𝗶𝗲𝘀 𝗜𝗻𝗰. Agents Only Technologies Inc. is a global workforce and operations company supporting technology, healthcare, customer experience, business operations, and professional services across multiple industries. We collaborate with organizations worldwide to deliver high-quality solutions through distributed networks, structured processes, and a commitment to operational excellence. Our global network of healthcare professionals supports specialized clinical review, medical documentation, utilization management, and healthcare content projects requiring strong subject-matter expertise and familiarity with the U.S. healthcare system. 𝗥𝗼𝗹𝗲 𝗢𝘃𝗲𝗿𝘃𝗶𝗲𝘄 We are seeking experienced healthcare professionals based in the United States to support a specialized clinical content and evaluation project across three areas of expertise 𝗧𝗶𝗲𝗿 𝟭 Prior Authorization & Utilization Review 𝗧𝗶𝗲𝗿 𝟮 Prior Authorization & Appeals Preparation 𝗧𝗶𝗲𝗿 𝟯 Medical Record Synthesis Contributors will be matched to a tier based on their professional qualifications, healthcare experience, and area of expertise. 𝗧𝗶𝗲𝗿 𝟭 – 𝗣𝗿𝗶𝗼𝗿 𝗔𝘂𝘁𝗵𝗼𝗿𝗶𝘇𝗮𝘁𝗶𝗼𝗻 & 𝗨𝘁𝗶𝗹𝗶𝘇𝗮𝘁𝗶𝗼𝗻 𝗥𝗲𝘃𝗶𝗲𝘄 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁 𝗥𝗼𝗹𝗲 𝗢𝘃𝗲𝗿𝘃𝗶𝗲𝘄 This role focuses on developing and evaluating realistic prior-authorization scenarios requiring clinical judgment and medical-necessity review. Contributors will apply utilization management principles, payer guidelines, and CMS coverage policies to determine whether a request should be 𝗔𝗽𝗽𝗿𝗼𝘃𝗲𝗱, 𝗗𝗲𝗻𝗶𝗲𝗱, 𝗼𝗿 𝗿𝗲𝘁𝘂𝗿𝗻𝗲𝗱 𝗳𝗼𝗿 𝗠𝗼𝗿𝗲 𝗜𝗻𝗳𝗼𝗿𝗺𝗮𝘁𝗶𝗼𝗻. 𝗔𝘀 𝗮 𝗧𝗶𝗲𝗿 𝟭 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁, 𝘆𝗼𝘂 𝘄𝗶𝗹𝗹 Author prior-authorization scenarios covering routine, complex, and safety-critical cases. Develop scenarios across specialties including radiology, surgery, cardiology, behavioral health, sleep studies, radiation therapy, spine/orthopedics, and DME. Create gold-standard Approve / Deny / Request More Information recommendations. Apply applicable CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Evaluate clinical documentation against medical-necessity criteria. Model appropriate Request More Information decisions when documentation is incomplete. Create evaluation rubrics assessing clinical reasoning and correct application of coverage policies. Participate in iterative review and evaluation cycles. Apply knowledge of U.S. payer utilization-management practices to clinical scenarios. 𝗥𝗲𝗾𝘂𝗶𝗿𝗲𝗱 𝗤𝘂𝗮𝗹𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀 Active U.S. RN license or MD/DO qualification. 3+ years of experience in utilization management, prior authorization, case management, clinical review, or payer-side medical review. Direct experience with U.S. healthcare utilization-management processes. Working knowledge of CMS NCD/LCD coverage determinations. Understanding of medical-necessity review standards. Ability to work across multiple clinical specialties. Strong clinical reasoning, documentation, and analytical skills. 𝗣𝗿𝗲𝗳𝗲𝗿𝗿𝗲𝗱 Peer-to-peer review experience. CPUR, ACM, or equivalent UM certification. Experience with Medicare, Medicaid, or commercial payer processes. Experience with clinical content authoring, data annotation, or evaluation projects. 𝗧𝗶𝗲𝗿 𝟮 – 𝗣𝗿𝗶𝗼𝗿 𝗔𝘂𝘁𝗵𝗼𝗿𝗶𝘇𝗮𝘁𝗶𝗼𝗻 & 𝗔𝗽𝗽𝗲𝗮𝗹𝘀 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁 𝗥𝗼𝗹𝗲 𝗢𝘃𝗲𝗿𝘃𝗶𝗲𝘄 This role focuses on the evidence-gathering and appeals preparation side of clinical review. Contributors will develop prior-authorization evidence packets and create physician-level appeal documentation demonstrating medical necessity following a denial. 𝗔𝘀 𝗮 𝗧𝗶𝗲𝗿 𝟮 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁, 𝘆𝗼𝘂 𝘄𝗶𝗹𝗹 Author scenarios requiring assembly of complete prior-authorization evidence packets. Review patient chart information and identify documentation supporting medical necessity. Draft gold-standard physician appeal letters addressing medical-necessity denials. Apply applicable CMS NCD/LCD requirements to appeal arguments. Research and cite relevant peer-reviewed medical literature, including PubMed sources. Ensure citations are current, relevant, and directly support the clinical argument. Create evaluation rubrics assessing evidence completeness and appeal quality. Evaluate the accuracy and strength of clinical arguments. Participate in iterative content review and evaluation cycles. Apply knowledge of U.S. payer denial and appeals processes. 𝗥𝗲𝗾𝘂𝗶𝗿𝗲𝗱 𝗤𝘂𝗮𝗹𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀 U.S.-licensed RN, MD/DO, or relevant clinical documentation professional. 3+ years of experience in prior authorization, utilization review, clinical documentation, denials, appeals, or related healthcare functions. Working knowledge of CMS NCD/LCD medical-necessity standards. Direct experience with U.S. healthcare documentation and payer processes. Ability to research and accurately cite peer-reviewed medical literature. Strong persuasive and evidence-based medical writing skills. 𝗣𝗿𝗲𝗳𝗲𝗿𝗿𝗲𝗱 Experience drafting real payer appeal letters. Experience working in a health plan or payer denials and appeals department. Medicare, Medicaid, or commercial insurance experience. Familiarity with literature search and evidence grading. Experience with clinical content authoring or healthcare data projects. 𝗧𝗶𝗲𝗿 𝟯 – 𝗠𝗲𝗱𝗶𝗰𝗮𝗹 𝗥𝗲𝗰𝗼𝗿𝗱 𝗦𝘆𝗻𝘁𝗵𝗲𝘀𝗶𝘀 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁 𝗥𝗼𝗹𝗲 𝗢𝘃𝗲𝗿𝘃𝗶𝗲𝘄 This role focuses on transforming complex, multi-visit medical records into accurate, chronological, and traceable clinical summaries. Contributors will review patient histories, identify clinically relevant patterns and redundant testing, and ensure each summary point can be linked back to its source documentation. 𝗔𝘀 𝗮 𝗧𝗶𝗲𝗿 𝟯 𝗦𝗽𝗲𝗰𝗶𝗮𝗹𝗶𝘀𝘁, 𝘆𝗼𝘂 𝘄𝗶𝗹𝗹 Author realistic multi-visit patient chart scenarios. Work with structured clinical data such as C-CDA XML and/or FHIR-formatted records. Create gold-standard chronological summaries of complex medical histories. Synthesize information across multiple encounters and clinical documentation sources. Identify duplicate or potentially redundant imaging, such as repeated CT or MRI studies. Ensure important summary points are traceable to specific source chart notes. Develop evaluation rubrics assessing summary completeness, accuracy, chronology, and source linkage. Review and refine clinical summaries through multiple evaluation cycles. Apply HIM/CDI principles when organizing and interpreting medical records. 𝗥𝗲𝗾𝘂𝗶𝗿𝗲𝗱 𝗤𝘂𝗮𝗹𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀 Background in Health Information Management (HIM), Clinical Documentation Improvement (CDI), or a related healthcare discipline. 3+ years of relevant professional experience. Experience reviewing multi-encounter medical records. Strong medical summarization and structured-writing skills. Experience identifying clinically redundant or repeated testing. Working knowledge of C-CDA XML and/or FHIR clinical data structures. Familiarity with U.S. healthcare documentation and clinical workflows. 𝗣𝗿𝗲𝗳𝗲𝗿𝗿𝗲𝗱 RHIA or RHIT certification. CDIP or CCDS certification. Familiarity with HEDIS/MIPS quality measures. Experience with clinical data annotation, content authoring, or evaluation projects. 𝗘𝗱𝘂𝗰𝗮𝘁𝗶𝗼𝗻 / 𝗘𝘅𝗽𝗲𝗿𝘁𝗶𝘀𝗲 Candidates with educational background or professional experience in one or more of the following areas are encouraged to apply Nursing Medicine Health Information Management Clinical Documentation Improvement Clinical Informatics Utilization Management Medical Review Healthcare Administration Related healthcare disciplines Equivalent professional experience may also be considered. 𝗝𝗼𝗯 𝗗𝗲𝘁𝗮𝗶𝗹𝘀 𝗧𝘆𝗽𝗲 Independent Contractor 𝗠𝗮𝗿𝗸𝗲𝘁 United States 𝗟𝗼𝗰𝗮𝘁𝗶𝗼𝗻 Remote 𝗖𝗼𝗺𝗽𝗲𝗻𝘀𝗮𝘁𝗶𝗼𝗻 Paid hourly 𝗦𝘁𝗮𝗿𝘁 𝗗𝗮𝘁𝗲 Based on project requirements 𝗢𝗽𝗲𝗻𝗶𝗻𝗴𝘀 Project-based and subject to client demand 𝗜𝗺𝗽𝗼𝗿𝘁𝗮𝗻𝘁 𝗡𝗼𝘁𝗲𝘀 Candidates may be considered for one or more tiers based on their professional background and area of expertise. U.S. healthcare experience is required for Tier 1 and Tier 2. Tier 1 and Tier 2 assignments require familiarity with U.S. payer processes and applicable CMS coverage policies. Tier 3 assignments require strong medical-record review and clinical documentation expertise. Strong attention to clinical accuracy, evidence quality, source traceability, and project guidelines is required. Project scope and task availability may vary based on business requirements. 𝗪𝗼𝗿𝗸 𝗔𝗿𝗿𝗮𝗻𝗴𝗲𝗺𝗲𝗻𝘁 𝗟𝗼𝗰𝗮𝘁𝗶𝗼𝗻 Remote – United States 𝗪𝗼𝗿𝗸 𝗧𝘆𝗽𝗲 Independent Contractor 𝗦𝗰𝗵𝗲𝗱𝘂𝗹𝗲 Project-dependent / Flexible 𝗦𝗰𝗼𝗽𝗲 United States 𝗖𝗼𝗺𝗽𝗲𝗻𝘀𝗮𝘁𝗶𝗼𝗻 Actual earnings may vary based on task availability, productivity, quality performance, project requirements, certifications, domain expertise, and business needs. 𝗛𝗼𝘄 𝘁𝗼 𝗔𝗽𝗽𝗹𝘆 Interested candidates may submit their application through the official application process. Please indicate your primary area of expertise Tier 1 – Prior Authorization & Utilization Review Tier 2 – Prior Authorization & Appeals Tier 3 – Medical Record Synthesis Please ensure your profile accurately reflects your professional license, healthcare experience, certifications, utilization-management or documentation experience, and relevant U.S. healthcare experience. Only shortlisted candidates will be contacted. 𝗘𝗾𝘂𝗮𝗹 𝗢𝗽𝗽𝗼𝗿𝘁𝘂𝗻𝗶𝘁𝘆 Agents Only Technologies Inc. is committed to fostering an inclusive, diverse global network. All opportunities are provided based on qualifications, skills, and business needs.