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Clinical Quality Reviewer
Virtix HealthClinical Quality Reviewer supporting Virtix Health’s healthcare prior authorization services. Reviewing clinical documentation, validating AI-assisted determinations, and ensuring CMS-compliant workflows.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review processes, including prior authorization and medical necessity evaluations, while effectively collaborating with multidisciplinary teams. Proficient in utilizing healthcare technology platforms and applying clinical judgment within regulated workflows.
Highest-signal resume keywords
Active Clinical Licensure (RN)Clinical Documentation ReviewCPT and ICD-10 CodingUtilization Management ExperienceHealthcare Technology Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical ReviewMedical Necessity EvaluationDocumentation ValidationQuality AssuranceClinical Judgment ApplicationAI-Assisted Review ValidationCPT CodingICD-10 CodingPrior Authorization WorkflowsOperational Continuity Support
Soft Skills
Analytical SkillsWritten CommunicationVerbal CommunicationCollaborationTeamwork
Tools & Technologies
Healthcare Technology PlatformsElectronic Clinical SystemsAI-Enabled Clinical Decision Support
Certifications & Qualifications
Active Clinical Licensure (RN)
Industry Keywords
Utilization ManagementPrior AuthorizationQuality AssuranceClinical ValidationRegulated Healthcare Environment
About the role
Key responsibilities & impact- Perform comprehensive clinical reviews of prior authorization requests according to CMS, WISeR, and internal policies
- Evaluate documentation for medical necessity, service appropriateness, LCDs, NCDs, and coverage criteria
- Validate AI-assisted review outcomes and escalate gaps, inconsistencies, or documentation deficiencies
- Prepare cases for physician review by summarizing clinical findings and identifying risks
- Validate Peer-to-Peer review eligibility, documentation sufficiency, and recorded outcomes
- Review expedited prior authorization requests and maintain CMS turnaround-time requirements
- Participate in quality assurance activities and identify trends affecting review quality
- Provide feedback to leadership and quality teams for process improvement and reviewer education
- Assist with clinical SOPs, Work Instructions, and review standards
- Review CPT and ICD-10 codes against clinical documentation and authorization determinations
- Support 24/7 clinical review operations, workload prioritization, expedited handling, and operational continuity
- Collaborate with physicians, customer service, quality, technology, Product, and Development teams
- Escalate operational or clinical risks
- Provide structured clinical feedback on AI-assisted review outputs
- Participate in testing and validation of clinical review and prior authorization technology
Requirements
What you’ll need- 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
- Prior experience supporting physician reviewers or Peer-to-Peer review processes 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
- Experience working in high-volume or highly regulated healthcare environments preferred
- 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
- Ability to work at a computer terminal for 6-8 hours a day
- Infrequently able to lift and move material weighing up to 20 lbs.
Benefits
Comp & perks- Equipment provided
- Professional development and personal growth opportunities
- Remote work within the United States
- Full-time schedule
- Flexible scheduling, including evenings, weekends, or holidays as operationally required