Remote Clinical Quality Auditor & PA Reviewer

Virtix Health, LLC.; Northern (KY); Remote; USD 85,000 - 110,000; Full time

Job summary

Virtix Health, LLC is seeking a Clinical Quality Reviewer (Coder/Auditor) to perform comprehensive clinical reviews for WISeR Prior Authorization, validating documentation for medical necessity under CMS guidelines. This remote US role operates in a 24/7 review environment and supports physician determinations.

The ideal candidate has CPT and ICD-10 coding experience, strong analytical and communication skills, and a certification from AAPC or AHIMA is preferred.

Qualifications

• Certification through AAPC or AHIMA preferred.
• Experience reviewing clinical documentation for medical necessity and appropriate care.
• Working knowledge of CPT and ICD-10 coding.
• Ability to apply clinical judgment within utilization management or prior authorization workflows.

Responsibilities

• Perform clinical reviews of prior authorization requests in accordance with CMS and WISeR guidelines.
• Validate documentation to determine medical necessity and service appropriateness.
• Identify gaps or deficiencies and escalate as needed for physician review.
• Review expedited prior authorization requests and prepayment reviews for CMS turnaround time compliance.
• Participate in quality assurance activities to ensure accuracy and regulatory compliance.
• Review CPT and ICD-10 codes and ensure alignment with documentation and determinations.
• Support cross-functional teams to maintain coverage, meet turnaround times, and ensure operational continuity.

Skills

Clinical review

CPT coding

ICD-10 coding

Analytical skills

Communication skills

Education

AAPC or AHIMA certification (preferred)

Tools

Healthcare IT systems

EHR / EMR

CMS guidelines

Job description

Virtix Health, LLC is seeking a Clinical Quality Reviewer (Coder/Auditor) to perform comprehensive clinical reviews for WISeR Prior Authorization, validating documentation for medical necessity under CMS guidelines. This remote US role operates in a 24/7 review environment and supports physician determinations.

The ideal candidate has CPT and ICD-10 coding experience, strong analytical and communication skills, and a certification from AAPC or AHIMA is preferred.