Clinical Quality Reviewer

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct thorough clinical assessments of prior authorization requests in compliance with CMS, WISeR, and internal policies.

• Assess documentation to determine medical necessity, appropriateness of services, LCDs, NCDs, and coverage criteria.

• Confirm AI-assisted review results and address gaps, inconsistencies, or documentation deficiencies.

• Prepare cases for physician evaluation by summarizing clinical findings and pinpointing associated risks.

• Validate eligibility for Peer-to-Peer reviews, ensuring documentation is sufficient and outcomes are accurately recorded.

• Review expedited prior authorization requests while adhering to CMS turnaround time requirements.

• Engage in quality assurance initiatives and identify trends that may impact review quality.

• Offer constructive feedback to leadership and quality teams aimed at enhancing processes and reviewer education.

• Assist in the development of clinical SOPs, Work Instructions, and review standards.

• Analyze CPT and ICD-10 codes in relation to clinical documentation and authorization decisions.

• Support 24/7 clinical review operations, prioritizing workloads and ensuring expedited handling and operational continuity.

• Collaborate with physicians, customer service, quality, technology, Product, and Development teams.

• Identify and escalate operational or clinical risks.

• Provide structured clinical feedback regarding AI-assisted review outputs.

• Participate in the testing and validation of clinical review and prior authorization technologies.

⛳️ Requirements

• Active clinical licensure (RN) is required.

• Proven experience in reviewing clinical documentation for medical necessity and appropriateness of care.

• Familiarity with CPT and ICD-10 coding.

• Capability to apply clinical judgment within regulated utilization management or prior authorization workflows.

• Proficient in healthcare technology platforms and electronic clinical systems.

• Strong analytical, written, and verbal communication abilities.

• Prior experience assisting physician reviewers or participating in Peer-to-Peer review processes is preferred.

• Experience in utilization management, quality assurance, audit support, or clinical validation roles is preferred.

• Exposure to AI-driven clinical decision support or healthcare technology initiatives is preferred.

• Experience in high-volume or highly regulated healthcare settings is preferred.

• Willingness to work flexible hours, including evenings, weekends, or holidays as needed.

• Comfortable in a fast-paced, technology-oriented environment.

• Strong teamwork and collaboration skills across clinical, operational, and technical teams.

• Ability to work at a computer terminal for 6-8 hours each day.

• Occasionally able to lift and move materials weighing up to 20 lbs.

🏝️ Benefits

• Equipment provided.

• Opportunities for professional development and personal growth.

• Remote work available within the United States.

• Full-time schedule.

• Flexible scheduling, including evenings, weekends, or holidays as operationally required.