Clinical Review Specialist

Job Description:

• Perform clinical reviews for medical necessity, level of care, and authorization-related denial
• Review inpatient and outpatient medical records to support appeal submissions
• Apply payer-specific guidelines (CMS, Medicaid, commercial) and internal policies
• Identify documentation gaps and support clear, defensible clinical narratives
• Meet assigned turnaround times while maintaining quality standards
• Document review findings accurately in designated systems
• Collaborate with clinical leadership as needed for escalations or complex cases

Requirements:

• Active, unrestricted RN license (compact preferred)
• Minimum 4–5 years of clinical experience
• 4+ years of Utilization Review, Appeals, or Clinical Review experience
• Strong knowledge of medical necessity criteria and payer guidelines
• Experience reviewing inpatient and/or outpatient hospital claims
• Proficiency with EMRs and review platforms (Epic preferred)
• Strong written clinical documentation and time management skills

Benefits:

• Work Expectations: Remote, independent work with defined productivity expectations
• Performance Expectations: Timely completion of assigned reviews
• Accurate application of clinical criteria and payer policy
• Clear, compliant documentation
• Ability to adapt to changing inventory and priorities