Overview
On Site
Up to $65
Contract - Independent
Contract - W2
Contract - 6 Month(s)
No Travel Required
Skills
Experience withCMS interoperability mandates(e.g.
CMS-0057-F
hub services
PA APIs). Knowledge of theLife Sciences value chain(pharma/biotech market access
patient support programs). Exposure toAI/ML or automationuse cases in pre-auth and utilization management. Prior experience in aconsulting or digital transformationenvironment.
Job Details
Job Description
Role Overview
We are seeking an experienced Life Sciences Business Architect / Domain Consultant with deep expertise in the Pre-Authorization (Pre-Auth) space within Life Sciences and Healthcare. The ideal candidate will have strong knowledge of payer, provider, and life sciences ecosystems, including regulatory frameworks, utilization management, patient access, and digital transformation trends. The role combines domain knowledge, client advisory, and solution design to drive strategic engagements for pharmaceutical, biotech, and med-tech clients.
Key Responsibilities
- Act as a subject matter expert (SME) in pre-authorization workflows, including medical necessity, clinical documentation, prior authorization rules, and payer–provider interactions.
- Support clients in transforming pre-auth processes to improve speed, compliance, and patient experience.
- Analyze current business processes, identify gaps, and design target operating models for pre-auth.
- Partner with technology teams to design and implement digital and GenAI-based pre-auth solutions (e.g., automated prior authorization, real-time benefit checks, EMR/EHR interoperability).
- Ensure compliance with CMS, FDA, and global regulations around pre-authorization, patient safety, and access.
- Work closely with product managers, architects, and delivery teams to ensure alignment between business requirements and technical solutions.
- Conduct workshops with client stakeholders to gather business needs, define KPIs, and build consensus.
- Contribute to thought leadership through white papers, PoVs, or webinars on pre-auth innovation and trends in life sciences.
Required Skills & Experience
- 7–12 years of experience in Life Sciences, Healthcare, or Payer/Provider domains, with 3–5 years focused on Pre-Authorization or Utilization Management.
- Strong understanding of:
- Prior authorization workflows (medical and pharmacy benefits)
- Interoperability standards (HL7 FHIR, X12, NCPDP)
- Clinical guidelines and evidence-based medical policy
- Patient access and affordability challenges
- Hands-on experience with provider-side processes and systems (EHR, claim processing, benefit management).
- Strong consulting, business analysis, and client-facing skills.
- Excellent communication, presentation, and stakeholder management skills.
Preferred Qualifications
- Experience with CMS interoperability mandates (e.g., CMS-0057-F, PA APIs).
- Knowledge of the Life Sciences value chain (pharma/biotech market access, hub services, patient support programs).
- Exposure to AI/ML or automation use cases in pre-auth and utilization management.
- Prior experience in a consulting or digital transformation environment.
- Bachelor’s or Master’s degree in Life Sciences, Healthcare Management, Pharmacy, or related field; MBA preferr
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