Clinical Quality Reviewer, Coder/Auditor

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 22%

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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 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

• 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

• Equipment provided • Professional development and personal growth opportunities