Clinical Quality Reviewer, Coder/Auditor

🔥 15 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 23%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Virtix Health

WebsiteLinkedInAll Job Openings

11 - 50 employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance • Technology

Virtix Health is a company that partners with health plans across the country to enhance clinical, financial, and operational outcomes. They offer a variety of services, including virtual wellness visits, in-home health risk assessments, retrospective chart review, workflow technology, and patient engagement services. They specialize in risk adjustment coding and clinical data connectivity, providing technology solutions that automate data acquisition and improve the management of medical records. Their aim is to innovate how healthcare data is exchanged to elevate the performance of health plans of all sizes.

📋 Description

• 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

• 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

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

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