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Clinical Quality Reviewer, Coder/Auditor
Virtix Health. Perform comprehensive clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies and procedures .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review processes, including evaluating medical necessity and appropriateness of care, while ensuring compliance with CMS, LCDs, and NCDs. Proficient in utilizing healthcare technology platforms and coding systems to support prior authorization workflows and quality assurance activities.
Highest-signal resume keywords
Clinical Documentation ReviewCPT and ICD-10 CodingUtilization ManagementQuality AssuranceHealthcare Technology Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewMedical Necessity EvaluationDocumentation ValidationAI-Assisted ReviewCPT CodingICD-10 CodingPrior Authorization WorkflowsQuality Assurance ActivitiesOperational Continuity SupportClinical Judgment Application
Soft Skills
Analytical SkillsWritten CommunicationVerbal CommunicationCollaborationTeamwork
Tools & Technologies
Healthcare Technology PlatformsElectronic Clinical Systems
Certifications & Qualifications
AAPC CertificationAHIMA CertificationCoding Credential from AAPC or AHIMA
Industry Keywords
CMS ComplianceLCD RequirementsNCD RequirementsUtilization ManagementClinical ValidationAudit SupportHealthcare Environment
About the role
Key responsibilities & impact- Perform comprehensive 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 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 affecting review quality or outcomes
- Provide feedback to leadership and quality teams to support process improvement and reviewer education
- Assist with development, review, and adherence to clinical SOPs, Work Instructions, and review standards
- Review and interpret CPT and ICD-10 codes in relation to clinical documentation
- Ensure alignment between documentation, coding, and authorization determinations
- Support clinical review operations, 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 testing and validation of technology supporting clinical review and prior authorization processes
Requirements
What you’ll need- Certification through either the AAPC or AHIMA — preferred
- 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
- Experience with LCD and Medicare coverage requirements — preferred
- Experience in utilization management, quality assurance, audit support, or clinical validation roles — preferred
- Exposure to AI-enabled clinical decision support or healthcare technology initiatives — preferred
- Experience working in high-volume or highly regulated healthcare environments — preferred
- Ability to work flexible schedules, including evenings, weekends, or holidays as operationally required
- Comfortable working in a fast-paced, 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 a day
- Ability to lift and move material weighing up to 20 lbs. infrequently
Benefits
Comp & perks- Equipment provided
- Professional development and personal growth opportunities