Infusions Documentation and Criteria Reviewer

Schedule: Monday-Friday, 9:00 AM-5:00 PM
Work Arrangement: Remote
Equipment: Client-provided equipment

About the Role

We are seeking a highly analytical and detail-oriented Infusions Documentation and Criteria Reviewer to support healthcare documentation review and criteria-based decision-making. This role is ideal for someone who enjoys investigating complex cases, interpreting healthcare policies, identifying gaps in documentation, and using critical thinking to reach well-supported conclusions.

The ideal candidate brings healthcare experience along with strong analytical skills, curiosity, independent problem-solving abilities, and comfort working with evolving technology and AI tools.

• Review clinical and operational documentation and assessment outcomes for completeness, accuracy, and consistency.

• Identify discrepancies, documentation gaps, exceptions, and areas requiring additional review.

• Compare records against applicable policies, procedures, coverage criteria, and regulatory standards.

• Analyze supporting documentation and multiple sources of information to validate determinations and recommendations.

• Interpret complex healthcare policies and apply criteria consistently to individual cases.

• Research ambiguous situations and investigate issues rather than relying solely on predefined workflows.

• Document findings clearly and provide structured, evidence-based feedback.

• Identify trends, patterns, and root causes that may impact documentation quality or review accuracy.

• Collaborate with cross-functional teams to improve review workflows, documentation standards, and overall quality.

• Contribute to process improvement initiatives by identifying opportunities to make criteria and workflows more consistent and efficient.

• Utilize AI and other technology tools to support research, analysis, documentation, and problem-solving while independently validating results.

• Experience in healthcare operations, documentation review, utilization management/review, case management, reimbursement support, quality assurance, audit, appeals, compliance, or a related healthcare function.

• Ability to interpret healthcare policies, clinical guidelines, payer requirements, and documentation standards.

• Strong analytical and investigative thinking with the ability to explain the reasoning behind decisions.

• Experience reviewing complex records and identifying discrepancies or missing information.

• Knowledge of healthcare reimbursement processes and coverage guidelines.

• Strong written and verbal communication skills.

• Excellent attention to detail and organizational skills.

• Ability to work independently and make sound decisions when information is incomplete or ambiguous.

• Demonstrated ability to research questions, evaluate multiple sources, and determine appropriate next steps.

• Experience with utilization management audits, payment integrity, clinical appeals, CDI audits, claims investigations, medical policy analysis, clinical informatics, or prior authorization quality/audit functions.

• Experience evaluating complex clinical or operational records.

• Familiarity with healthcare coding systems and documentation standards.

• Experience with healthcare technology platforms and workflow tools.

• Experience working in a remote environment.

• Experience using AI tools such as ChatGPT, Claude, Gemini, Microsoft Copilot, or similar platforms for research, analysis, documentation, or problem-solving.

AI fluency is an important component of this role. The ideal candidate regularly uses AI as a thinking and productivity partner, not simply as an email-writing tool.

Strong candidates will be able to demonstrate how they:

• Use AI multiple times per day or on a daily basis.

• Use AI to analyze information, research topics, summarize documentation, troubleshoot problems, brainstorm solutions, or improve workflows.

• Write and refine effective prompts.

• Break complex problems into smaller steps when working with AI.

• Validate AI-generated information rather than accepting results at face value.

• Recognize when AI produces inaccurate or incomplete information and know how to correct or improve the output.

• Adapt quickly to new AI tools and technologies.

The strongest candidates are naturally curious and enjoy solving problems that do not always have an obvious answer. They question assumptions, investigate before reaching conclusions, recognize patterns, and can clearly explain why they reached a particular determination.

This position is best suited for someone who:

• Enjoys researching and solving ambiguous problems.

• Thinks logically and systematically.

• Questions policies and documentation when something does not make sense.

• Can distinguish between policy requirements and operational workflows.

• Takes ownership rather than waiting for step-by-step instructions.

• Learns new tools and concepts independently.

• Is comfortable saying, "I don't know, but here's how I would find out."

• Looks for opportunities to improve processes rather than simply following them.

Candidates with experience in the following areas may be especially relevant:

• Utilization Management / Utilization Review

• Payment Integrity

• Clinical Appeals

• CDI Audit

• Claims Investigation

• Medical Policy Analysis

• Clinical Informatics

• Prior Authorization - particularly quality, escalation, or audit functions

• Healthcare Quality Assurance

• Healthcare Compliance

• Reimbursement Review

Candidates whose backgrounds are primarily high-volume transaction processing, routine data entry, administrative coordination, or strictly workflow-driven prior authorization processing may be less aligned with the analytical nature of this position.

• Schedule: Monday-Friday, 9:00 AM-5:00 PM

• Work Arrangement: Remote

• Equipment: Provided by client

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?