Clinical Quality Reviewer (Coder/Auditor)

CorroHealth Inc; United States; Remote; USD 80,000 - 120,000; Full time

Job summary

CorroHealth Inc is seeking a Remote Clinical Review & Prior Authorization Specialist in the United States. You will perform clinical reviews of PA requests, assess medical necessity, and validate AI-assisted outputs to ensure accurate determinations.

You will collaborate with physicians, coding teams, and QA to maintain CMS turnaround times and compliance. Strong CPT/ICD-10 knowledge and certified coding credentials are preferred.

Qualifications

• Certification through AAPC or AHIMA is preferred.
• 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 utilization management workflows.
• Proficiency with healthcare technology platforms and electronic clinical systems.

Responsibilities

• Perform clinical reviews of prior authorization requests for medical necessity and appropriateness.
• Validate AI-assisted review outputs, identify gaps, and escalate deficiencies as needed.
• Review expedited prior authorization and prepayment requests ensuring CMS requirements are met.
• Collaborate with physicians, QA, and coding teams to maintain turnaround times and quality standards.

Skills

AAPC/AHIMA certification

CPT coding

ICD-10 coding

clinical judgment

healthcare IT systems

communication skills

Job description

About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

JOB SUMMARY: ESSENTIAL DUTIES AND RESPONSIBILITIES:

Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. This position is REMOTE within US Only - Equipment provided.

Clinical Review & Prior Authorization Support

Perform clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies and procedures. Evaluate clinical documentation to determine medical necessity, service appropriateness, and alignment with applicable LCDs, NCDs, and coverage criteria. Validate AI‑assisted review outcomes, identifying gaps, inconsistencies, or documentation deficiencies requiring escalation. Prepare cases for physician review by summarizing clinical findings, identifying risks, and supporting accurate determinations. Review and validate expedited prior authorization requests & prepayment reviews, ensuring urgency criteria are met, documentation supports expedited handling, and CMS turnaround time requirements are maintained.

Quality Assurance & Compliance

Participate in quality assurance activities to ensure accuracy, consistency, and regulatory compliance across clinical determinations. Identify trends, documentation gaps, and recurring issues 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.

Coding & Documentation Accuracy

Review and interpret CPT procedure codes and ICD‑10 diagnosis codes in relation to clinical documentation. Ensure accurate alignment between documentation, coding, and authorization determinations. Identify documentation deficiencies and recommend corrective actions to support compliant decision‑making and audit readiness.

Operational & Cross‑Functional Support

Support a clinical review operation, including participation in non‑traditional scheduling as needed to ensure continuous coverage. Assist with workload prioritization, expedited case handling, and operational continuity. Collaborate with physicians, customer service, quality, and technology teams to meet turnaround time (TAT), service level, and quality expectations. Escalate operational or clinical risks appropriately and in a timely manner.

Technology & Workflow Collaboration

Provide structured clinical feedback on AI‑assisted review outputs to improve model accuracy and clinical relevance. Collaborate with Product and Development teams on workflow optimization, system enhancements, and clinical validation initiatives. Participate in testing and validation of technology used to support clinical review and prior authorization processes.

Required Qualifications

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.

Preferred Qualifications

Experience in LCD, Medicare coverage requirements Utilization management, quality assurance, audit support, or clinical validation roles.
Exposure to AI‑enabled clinical decision support or healthcare technology initiatives.
Experience working in high‑volume or highly regulated healthcare environments.

Work Requirements

This position is REMOTE within US Only - Equipment provided.
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.

PHYSICAL DEMANDS

Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye‑hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.

The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. Virtix Health partners with health plans across the country to drive clinical, financial, and operational results. Virtix Health offers virtual wellness visits, in‑home health risk assessments, retrospective chart review, HCC Coding, medical record repository, retrieval workflow technology, health risk assessments, and member engagement services.