Clinical Decision Review Specialist

Company Description Luna Health Solutions works to simplify medication access for patients and healthcare partners by reducing the complexity of benefit programs, prior authorizations, and affordability challenges. The company combines high-touch member engagement, clinical expertise, technology, and healthcare operations to connect patients with appropriate resources. Luna Health supports prior authorization services, clinical decision support, and member outreach to improve access and adherence. By streamlining these workflows, Luna Health helps lower administrative burdens for payers, PBMs, and manufacturers while aiming to enhance patient experiences and outcomes.

Role Description The Clinical Decision Review Specialist is a full-time remote role responsible for reviewing clinical information to support appropriate medication access and utilization decisions. This role involves evaluating prior authorization requests, applying evidence-based clinical criteria, and documenting clear recommendations that align with organizational policies and regulatory standards. The specialist will collaborate with internal teams and external partners to clarify clinical details, communicate outcomes, and support consistent decision-making. Daily activities include analyzing medical records, researching clinical guidelines, contributing to quality improvement efforts, and providing input on training materials and best practices for clinical workflows.

Qualifications

• Clinical and medical knowledge: candidates should possess skills in Medicine and Clinical Research to interpret clinical data and apply evidence-based criteria.
• Communication and collaboration: candidates should possess strong Communication skills to explain decisions clearly and work effectively with cross-functional teams and external stakeholders.
• Training and knowledge sharing: candidates should possess skills in Training to support education on clinical policies, workflows, and decision standards.
• Analytical and evidence-based practice: candidates should possess skills in Research to review clinical literature, guidelines, and emerging best practices.
• Relevant education and credentials, such as a degree in a medical/health-related field (Physician, Pharmacist) or equivalent clinical experience.
• 3+ years Experience in utilization management, prior authorization, or managed care environments is strongly preferred.
• Ability to work independently in a remote setting, manage multiple cases, and maintain accuracy and attention to detail.
• Familiarity with healthcare regulations, payer policies, and electronic medical record or case management systems is beneficial.