Clinical Quality Reviewer

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 15%

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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 according to CMS, WISeR, and internal policies • Evaluate 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 • Validate Peer-to-Peer review eligibility, documentation sufficiency, and recorded outcomes • Review expedited prior authorization requests and maintain CMS turnaround-time requirements • Participate in quality assurance activities and identify trends affecting review quality • Provide feedback to leadership and quality teams for process improvement and reviewer education • Assist with clinical SOPs, Work Instructions, and review standards • Review CPT and ICD-10 codes against clinical documentation and authorization determinations • Support 24/7 clinical review operations, workload prioritization, expedited handling, and operational continuity • Collaborate with physicians, customer service, quality, technology, Product, and Development teams • Escalate operational or clinical risks • Provide structured clinical feedback on AI-assisted review outputs • Participate in testing and validation of clinical review and prior authorization technology

🎯 Requirements

• Active clinical licensure (RN) • 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 • Prior experience supporting physician reviewers or Peer-to-Peer review processes 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 • Infrequently able to lift and move material weighing up to 20 lbs.

🏖️ Benefits

• Equipment provided • Professional development and personal growth opportunities • Remote work within the United States • Full-time schedule • Flexible scheduling, including evenings, weekends, or holidays as operationally required