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 ensures clinically sound, timely, and compliant prior authorization determinations while collaborating with physicians, nurses, quality teams, customer service, and technology partners. The position operates in a 24/7 review environment and supports quality assurance initiatives and technology-enabled clinical review workflows.
Key responsibilities include:
- Perform clinical reviews of prior authorization requests in accordance with CMS, WISeR, and internal policies.
- Evaluate clinical documentation for medical necessity, service appropriateness, and alignment with LCDs, NCDs, and coverage criteria.
- Validate AI-assisted review outcomes and identify documentation gaps or inconsistencies requiring escalation.
- Prepare cases for physician review by summarizing clinical findings and identifying risks.
- Review expedited prior authorization requests and prepayment reviews to ensure urgency criteria and turnaround time requirements are met.
- Participate in quality assurance activities to improve accuracy, consistency, and regulatory compliance.
- Provide feedback on trends, documentation gaps, and recurring issues affecting review quality.
- Support clinical SOPs, work instructions, and review standards.
- Review and interpret CPT and ICD-10 codes in relation to clinical documentation.
- Collaborate with cross-functional teams to maintain operational continuity and meet service-level expectations.
- Provide structured feedback on AI-assisted review outputs and participate in workflow and technology validation efforts.
- Certification through AAPC or AHIMA preferred.
- Coding or auditing credential from AAPC or AHIMA required.
- 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.
- Experience with LCD and Medicare coverage requirements preferred.
- Experience in utilization management, quality assurance, audit support, or clinical validation roles preferred.
- Exposure to AI-enabled clinical decision support or healthcare technology initiatives preferred.
- Ability to work flexible schedules, including evenings, weekends, or holidays as needed.
- Comfortable working in a fast-paced, technology-driven environment.
- Remote work within the U.S.
- Equipment provided.
- Opportunity to work in a technology-enabled clinical review environment.
- Professional development and growth-focused culture.
Location
Texas, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
1 month ago