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 alignment with CMS, WISeR, and internal guidelines.

• Assess clinical documentation to determine medical necessity, appropriateness of services, as well as compliance with LCDs, NCDs, and coverage criteria.

• Confirm AI-assisted review results and report any discrepancies, inconsistencies, or documentation gaps.

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

• Review and authenticate expedited prior authorization requests and prepayment assessments.

• Engage in quality assurance initiatives and pinpoint trends and recurring challenges.

• Offer constructive feedback to leadership and quality teams to enhance processes and educate reviewers.

• Aid in the formulation, assessment, and adherence to clinical SOPs, work instructions, and review standards.

• Analyze CPT and ICD-10 codes against clinical documentation and authorization decisions.

• Identify documentation shortfalls and suggest corrective measures.

• Assist in prioritizing workloads, expediting case processing, and ensuring operational continuity.

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

• Appropriately and promptly escalate operational or clinical risks.

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

• Contribute to workflow optimization, system upgrades, and technology testing and validation.

⛳️ Requirements

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

• Familiarity with CPT and ICD-10 coding.

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

• Proficient in healthcare technology platforms and electronic clinical systems.

• Strong analytical, written, and verbal communication abilities.

• Coding or auditing certification from AAPC or AHIMA.

• Willingness to work Monday to Friday, from 8:00 AM to 5:00 PM PST (West Coast hours).

• Capability to operate in a 24/7 review setting and adapt to non-traditional schedules as required.

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

• Capacity to remain seated for extended periods and occasionally lift or move up to 20 lbs.

• Preferred: Certification from AAPC or AHIMA; experience with LCD and Medicare coverage requirements; background in utilization management, quality assurance, audit support, or clinical validation; exposure to AI-enabled clinical decision support or healthcare technology initiatives; experience in high-volume or highly regulated healthcare environments.

🏝️ Benefits

• Opportunities for professional development and personal growth.

• Investment in employee career advancement.

• Reasonable accommodations for individuals with disabilities.