Certified Clinical Quality Reviewer

Job Summary

Working remotely on a full-time basis, the Certified Clinical Quality Reviewer will perform comprehensive clinical reviews and validate documentation accuracy for prior authorization requests, ensuring compliance with CMS requirements and organizational policies.

Key responsibilities

• Conduct clinical reviews of prior authorization requests, evaluating documentation for medical necessity and compliance
• Participate in quality assurance activities to ensure accuracy and regulatory compliance across clinical determinations
• Review and interpret CPT and ICD 10 coding to ensure alignment between documentation and authorization determinations

Required qualifications

• 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
• Coding or Auditing credential from AAPC or AHIMA