ODM/ADM Legacy Prior Authorization Specialist

PENNEP is seeking an experienced ODM/ADM Legacy Prior Authorization Specialist to support the design, configuration, and optimization of prior authorization and utilization management systems, to join our client’s dynamic team. This role requires strong expertise in rules engine configuration (Oracle Decision Management / ADM), deep knowledge of prior authorization workflows, and the ability to translate clinical and regulatory requirements into automated decision logic.

• Design, configure, and maintain Oracle Decision Management (ODM) / ADM rules engines for prior-authorization workflows.
• Translate Local Coverage Determinations (LCDs) and clinical policies into executable rules logic.
• Support and enhance prior authorization and utilization management systems and processes.
• Leverage strong SQL, SSIS, and Oracle skills for data analysis, integration, and system optimization.
• Ensure accurate handling and processing of X12 278 transactions for prior authorization requests and responses.
• Collaborate with business, clinical, and IT stakeholders to define and implement decision automation requirements.
• Integrate rules engines with claims adjudication systems (e.g., HealthEdge or similar platforms).
• Perform testing, validation, and troubleshooting of rules and workflows to ensure accuracy and compliance.
• Support system modernization, including legacy transformation and migration efforts.
• Maintain documentation for rules logic, system configurations, and processes.

• 5+ years in prior-authorization or utilization management technology.
• Strong SQL, SSIS, and Oracle; hands-on Oracle Decision Management / ADM rules engine configuration.
• X12 278 transaction fluency; experience translating Local Coverage Determinations into rules logic.

• HealthEdge or comparable claims adjudication system experience a plus.
• FHIR familiarity beneficial.

A minimum of Bachelor's Degree

Contract

Remote Work