RN Clinical Quality Reviewer

Job Summary

Supporting the WISeR Prior Authorization Program, the full-time RN Clinical Quality Reviewer will perform comprehensive clinical reviews, validate documentation accuracy, and assist in physician determination activities, all while working remotely within the US.

Key responsibilities

• Conduct clinical reviews of prior authorization requests in compliance with CMS and internal policies
• Participate in quality assurance activities to ensure regulatory compliance and identify documentation gaps
• Collaborate with cross-functional teams to optimize workflows and support operational continuity in a 24/7 environment

Required qualifications

• Active clinical licensure as a Registered Nurse (RN)
• Experience in reviewing clinical documentation for medical necessity and appropriateness of care
• Working knowledge of CPT and ICD 10 coding
• Ability to apply clinical judgment within utilization management or prior authorization workflows
• Proficiency with healthcare technology platforms and electronic clinical systems