Clinical Review Specialist

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

📋 Description

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

• Evaluate both inpatient and outpatient medical records to facilitate appeal submissions.

• Utilize payer-specific guidelines (CMS, Medicaid, commercial) alongside internal policies.

• Detect documentation deficiencies and aid in creating clear, defensible clinical narratives.

• Adhere to assigned turnaround times while upholding quality standards.

• Accurately document review outcomes in the specified systems.

• Collaborate with clinical leadership when necessary for escalations or intricate cases.

⛳️ Requirements

• Valid, unrestricted RN license (compact preferred).

• At least 4–5 years of clinical experience.

• Minimum of 4 years in Utilization Review, Appeals, or Clinical Review roles.

• Comprehensive understanding of medical necessity criteria and payer regulations.

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

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

• Excellent written clinical documentation and time management abilities.

🏝️ Benefits

• Work Expectations: Remote, independent work with clearly defined productivity standards.

• Performance Expectations: Prompt completion of assigned reviews.

• Accurate application of clinical criteria and payer policies.

• Clear and compliant documentation.

• Capacity to adjust to shifting inventory and priorities.