Clinical Review Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Prepare and submit appeals concerning DRG downgrades and clinical validation denials.

• Conduct clinical assessments for medical necessity, level of care, and authorization-related denials.

• Examine inpatient and outpatient medical records to substantiate appeal submissions.

• Utilize payer-specific guidelines, including CMS, Medicaid, and commercial standards, alongside internal policies.

• Identify gaps in documentation and assist in formulating clear, defensible clinical narratives.

• Adhere to assigned turnaround times while upholding quality standards.

• Accurately document review outcomes in designated systems.

• Collaborate with clinical leadership regarding escalations and complex cases.

• Manage assigned inventory and adapt to shifting priorities.

⛳️ Requirements

• Permanent work status is mandatory.

• An active, unrestricted RN license is required (compact preferred).

• A minimum of 4–5 years of clinical experience is necessary.

• At least 4 years of experience in DRG, Utilization Review, Appeals, or Clinical Review is essential.

• Strong understanding of medical necessity criteria and payer guidelines is required.

• Experience in reviewing inpatient and/or outpatient hospital claims is important.

• Proficiency in EMRs and review platforms (Epic preferred).

• Excellent written clinical documentation and time management skills are needed.

• Must be able to work Monday–Friday, from 8:00 AM to 5:00 PM.

• Capacity to work independently in a remote setting with defined productivity expectations.

• Ability to operate at a computer terminal for 6–8 hours per day.

• Capability to sit for extended periods.

• Occasionally able to lift and move materials weighing up to 20 lbs.

🏝️ Benefits

• Full-time employment.

• Remote work opportunities within the United States.

• Opportunities for professional development and personal growth.

• Long-term career advancement supported by employer investment.

• Reasonable accommodations provided for individuals with disabilities.