Clinical Quality Reviewer

Job Summary

Supporting the WISeR Prior Authorization Program, the full-time Clinical Quality Reviewer will perform comprehensive clinical reviews, validate documentation accuracy, and assist in prior authorization determinations while working remotely within the U.S.

Key responsibilities

• Conduct clinical reviews of prior authorization requests to ensure compliance with CMS, WISeR, and internal policies
• Participate in quality assurance activities to maintain accuracy and regulatory compliance across clinical determinations
• Review and interpret CPT and ICD 10 codes, ensuring alignment between documentation and authorization determinations

Required qualifications

• Certification through either the AAPC or AHIMA is preferred
• Demonstrated experience in reviewing clinical documentation for medical necessity
• Working knowledge of CPT and ICD 10 coding
• Ability to apply clinical judgment in regulated utilization management workflows
• Proficiency with healthcare technology platforms and electronic clinical systems