Remote Clinical Reviewer: Prior Authorization & QA

CorroHealth Inc; Washington; Hybrid; USD 70,000 - 95,000; Full time

Job summary

Virtix Health is seeking a remote Clinical Reviewer (RN) to support the WISeR Prior Authorization program. You will perform clinical reviews, validate documentation, and support physician determinations in CMS-compliant workflows.

This 24/7 operation requires strong analytical skills, experience with CPT/ICD-10 coding, and collaboration with physicians, quality teams, and IT partners to ensure timely, accurate prior authorizations within CMS timelines.

Qualifications

• Active RN licensure and ability to practice clinically.
• 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 workflows.
• Proficiency with healthcare technology platforms and electronic clinical systems.
• Strong analytical, written, and verbal communication skills.

Responsibilities

• Perform clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies.
• Evaluate documentation to determine medical necessity and alignment with LCDs, NCDs, and coverage criteria.
• Validate AI-assisted review outputs and escalate gaps as needed.
• Prepare cases for physician review with summarized findings and risks.
• Support Peer-to-Peer (P2P) review processes and expedite handling when appropriate.
• Contribute to quality assurance and SOP development.

Skills

RN licensure

Clinical review

CPT/ICD-10 coding

Documentation accuracy

Analytical thinking

Tools

EHR systems

Job description

Virtix Health is seeking a remote Clinical Reviewer (RN) to support the WISeR Prior Authorization program. You will perform clinical reviews, validate documentation, and support physician determinations in CMS-compliant workflows.

This 24/7 operation requires strong analytical skills, experience with CPT/ICD-10 coding, and collaboration with physicians, quality teams, and IT partners to ensure timely, accurate prior authorizations within CMS timelines.