Clinical Quality Reviewer, Coder/Auditor

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

📋 Description

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

• Assess clinical documentation for medical necessity, appropriateness of services, and conformity with LCDs, NCDs, and coverage guidelines.

• Confirm the outcomes of AI-assisted reviews and report any gaps, inconsistencies, or documentation issues.

• Compile cases for physician assessment by summarizing clinical findings and highlighting potential risks.

• Analyze and validate expedited prior authorization requests as well as prepayment reviews.

• Engage in quality assurance initiatives and recognize trends that impact review quality or results.

• Offer constructive feedback to leadership and quality teams to enhance process efficiency and reviewer training.

• Assist in the creation, evaluation, and adherence to clinical SOPs, work instructions, and review standards.

• Interpret and review CPT and ICD-10 codes in relation to clinical documentation.

• Ensure consistency among documentation, coding, and authorization decisions.

• Facilitate clinical review operations, prioritize workload, manage expedited cases, and maintain operational continuity.

• Collaborate with physicians, customer service, quality assurance, technology, product, and development teams.

• Timely escalate operational or clinical risks as necessary.

• Provide structured clinical insights on AI-assisted review results.

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

⛳️ Requirements

• Certification from either the AAPC or AHIMA is preferred.

• 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.

• Excellent analytical, written, and verbal communication abilities.

• Coding or auditing credential from AAPC or AHIMA is preferred.

• Experience with LCD and Medicare coverage requirements is preferred.

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

• Familiarity with AI-enabled clinical decision support or healthcare technology projects 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 operating in a dynamic, technology-driven environment.

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

• Ability to work at a computer terminal for 6–8 hours per day.

• Capability to lift and transport materials weighing up to 20 lbs. infrequently.

🏝️ Benefits

• Equipment provided.

• Opportunities for professional development and personal growth.