Clinical Quality Reviewer (Coder/Auditor)
About The Position
The Clinical Quality Reviewer supports the WISeR Prior Authorization Program by conducting comprehensive clinical reviews, validating documentation accuracy, and supporting physician determination activities in compliance with CMS requirements, WISeR guidelines, and organizational policies. The role helps ensure clinically sound, timely, and compliant prior authorization determinations. The reviewer applies clinical expertise and analytical and documentation skills while collaborating with physicians, nurses, quality teams, customer service, and technology partners. The position operates within a 24/7 review environment and supports quality assurance initiatives and technology-enabled clinical review workflows. The role is remote within the United States and requires a Monday–Friday schedule from 8:00 AM to 5:00 PM PST; willingness to work West Coast hours is required.
Requirements
- Demonstrated experience reviewing clinical documentation for medical necessity and appropriateness of care.
- Working knowledge of CPT and ICD-10 coding.
- Ability to apply clinical judgment within regulated utilization management or prior authorization workflows.
- Proficiency with healthcare technology platforms and electronic clinical systems.
- Strong analytical, written, and verbal communication skills.
- Coding or Auditing credential from AAPC or AHIMA.
- Must be willing to work Monday through Friday, 8:00 AM to 5:00 PM PST.
- Must be located within the United States for remote work.
Nice To Haves
- Certification through AAPC or AHIMA.
- Experience with LCDs and Medicare coverage requirements.
- Experience in utilization management, quality assurance, audit support, or clinical validation roles.
- Exposure to AI-enabled clinical decision support or healthcare technology initiatives.
- Experience working in high-volume or highly regulated healthcare environments.
Responsibilities
- Conduct clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies and procedures.
- Evaluate clinical documentation for medical necessity, service appropriateness, and alignment with applicable LCDs, NCDs, and coverage criteria.
- Validate AI-assisted review outcomes and identify gaps, inconsistencies, or documentation deficiencies requiring escalation.
- Prepare cases for physician review by summarizing clinical findings, identifying risks, and supporting accurate determinations.
- Review and validate expedited prior authorization requests and prepayment reviews, confirming urgency criteria and supporting documentation while maintaining CMS turnaround time requirements.
- Participate in quality assurance activities to support accuracy, consistency, and regulatory compliance across clinical determinations.
- Identify trends, documentation gaps, and recurring issues affecting review quality or outcomes.
- Provide feedback to leadership and quality teams to support process improvement and reviewer education.
- Assist with the development and review of, and adherence to, clinical SOPs, work instructions, and review standards.
- Review and interpret CPT procedure codes and ICD-10 diagnosis codes in relation to clinical documentation.
- Ensure alignment among documentation, coding, and authorization determinations; identify documentation deficiencies and recommend corrective actions.
- Support clinical review operations, including non-traditional scheduling as needed for continuous coverage.
- Assist with workload prioritization, expedited case handling, and operational continuity.
- Collaborate with physicians, customer service, quality, and technology teams to meet turnaround time, service-level, and quality expectations.
- Escalate operational or clinical risks appropriately and promptly.
- Provide structured clinical feedback on AI-assisted review outputs to improve model accuracy and clinical relevance.
- Collaborate with Product and Development teams on workflow optimization, system enhancements, and clinical validation initiatives.
- Participate in testing and validation of technology used to support clinical review and prior authorization processes.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
