Clinical Quality Reviewer, Coder/Auditor

Virtix Health

. Perform comprehensive clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies .

Posted 10/30/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation review for medical necessity and appropriateness of care, with proficiency in CPT and ICD-10 coding. Capable of applying clinical judgment within regulated utilization management workflows and collaborating effectively with multidisciplinary teams.

Highest-signal resume keywords

Clinical Documentation ReviewCPT CodingICD-10 CodingUtilization ManagementQuality Assurance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity EvaluationDocumentation ValidationRisk IdentificationWorkflow Optimization

Soft Skills

Analytical SkillsWritten CommunicationVerbal Communication

Tools & Technologies

Healthcare Technology PlatformsElectronic Clinical Systems

Certifications & Qualifications

AAPC CredentialAHIMA Credential

Industry Keywords

Prior AuthorizationLCDNCDAI-Assisted ReviewOperational Continuity

About the role

Key responsibilities & impact

Perform comprehensive clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies
Evaluate clinical documentation for medical necessity, service appropriateness, LCDs, NCDs, and coverage criteria
Validate AI-assisted review outcomes and escalate gaps, inconsistencies, or documentation deficiencies
Prepare cases for physician review by summarizing clinical findings and identifying risks
Review and validate expedited prior authorization requests and prepayment reviews
Participate in quality assurance activities and identify trends and recurring issues
Provide feedback to leadership and quality teams for process improvement and reviewer education
Assist with development, review, and adherence to clinical SOPs, work instructions, and review standards
Review CPT and ICD-10 codes against clinical documentation and authorization determinations
Identify documentation deficiencies and recommend corrective actions
Support workload prioritization, expedited case handling, and operational continuity
Collaborate with physicians, customer service, quality, technology, Product, and Development teams
Escalate operational or clinical risks appropriately and timely
Provide structured clinical feedback on AI-assisted review outputs
Participate in workflow optimization, system enhancements, and technology testing and validation

Requirements

What you’ll need

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
Willingness to work Monday-Friday, 8:00 AM-5:00 PM PST (West Coast hours)
Ability to work in a 24/7 review environment and participate in non-traditional scheduling as needed
Ability to work at a computer terminal for 6-8 hours per day
Ability to sit for prolonged periods and occasionally lift/move up to 20 lbs
Preferred: Certification through AAPC or AHIMA; experience with LCD and Medicare coverage requirements; utilization management, quality assurance, audit support, or clinical validation experience; exposure to AI-enabled clinical decision support or healthcare technology initiatives; experience in high-volume or highly regulated healthcare environments

Benefits

Comp & perks

Professional development and personal growth opportunities
Investment in employee career development
Reasonable accommodations for individuals with disabilities