Domain Consultant – Pre-Authorization
2 weeks ago
Role: Domain Consultant – Pre-Authorization (Life Sciences / Healthcare)
Location: Valencia, CA
We are seeking an experienced Domain Consultant with deep expertise in the Pre-Authorization (Pre-Auth) space within Life Sciences and Healthcare. The ideal candidate will bring a strong understanding of payer, provider, and life sciences ecosystems, including regulatory frameworks, utilization management, patient access, and digital transformation trends. This role will combine 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, covering 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 existing business processes, identify gaps, and design target operating models for pre-auth.
• Partner with technology teams to shape digital and GenAI solutions (e.g., automated prior authorization, real-time benefit checks, interoperability with EMR/EHR).
• Advise on compliance with CMS, FDA, and global regulations around pre-authorization, patient safety, and access.
• Collaborate with product managers, architects, and delivery teams to ensure business requirements are translated into solution designs.
• Conduct workshops with client stakeholders to gather business requirements, define KPIs, and build consensus.
• Contribute to thought leadership (white papers, PoVs, webinars) on pre-auth trends and innovation in life sciences.
Required Skills & Experience
• 7–12 years of domain experience in Life Sciences, Healthcare, or Payer/Provider organizations, with at least 3–5 years focused on pre-authorization or utilization management.
Strong knowledge of:
o Prior authorization workflows (medical and pharmacy benefits)
o Interoperability standards (HL7 FHIR, X12, NCPDP)
o Clinical guidelines and evidence-based medical policy
o Patient access and affordability challenges
• Exposure to payer and provider systems (EHR, claim processing, benefit management).
• Experience in consulting or business analysis roles, preferably with global clients.
• Proven ability to liaise between business and technology teams.
• Excellent communication, presentation, and stakeholder management skills.
Preferred Qualifications
• Experience with CMS interoperability mandates (e.g., CMS-0057-F, PA APIs).
• Knowledge of life sciences value chain (pharma/biotech market access, hub services, patient support programs).
• Familiarity with AI/ML and automation use cases in pre-auth and utilization management.
• Prior experience in a consulting firm or digital transformation environment.
• Bachelor's or Master's degree in Life Sciences, Healthcare Management, Pharmacy, or related field; MBA preferred.
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