Clinical Quality Reviewer

 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

Required Schedule: Monday - Friday, 8:00 AM - 5:00 PM PST (Pacific West Coast)

The Clinical Reviewer supports the WISeR Prior Authorization Program by performing comprehensive clinical reviews, validating documentation accuracy, and supporting physician determination activities in compliance with CMS requirements, WISeR guidelines, and organizational policies. This role is responsible for ensuring clinically sound, timely, and compliant prior authorization determinations, including the validation of expedited cases and Peer‑to‑Peer (P2P) review workflows.

The Clinical Reviewer combines clinical expertise with strong analytical and documentation skills while collaborating with physicians, nurses, quality teams, customer service, and technology partners. This position operates within a 24/7 review environment and plays a key role in supporting quality assurance initiatives and technology‑enabled clinical review workflows.

Essential Duties and Responsibilities

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.
• Validate and support Peer‑to‑Peer (P2P) review processes, including confirmation of P2P eligibility, documentation sufficiency, and accurate reflection of outcomes in the case record.
• Review and validate expedited prior authorization requests, 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 24/7 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

• Active clinical licensure (RN)
• 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.

Preferred Qualifications

• Prior experience supporting physician reviewers or Peer‑to‑Peer review processes.
• Experience in 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

• 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.
A job description is only intended as a guideline and is only part of the Team Member’s function. 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.