PRN Clinical Review Nurse, RN

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

📋 Description

• Conduct clinical evaluations for medical necessity, levels of care, and authorization-related denials.

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

• Implement payer-specific guidelines along with internal policies.

• Recognize documentation deficiencies and assist in crafting clear, defensible clinical narratives.

• Adhere to assigned turnaround times while upholding quality standards.

• Accurately document review findings in designated systems.

• Collaborate with clinical leadership for escalations or intricate cases.

• Offer clinical review assistance as needed to manage inventory fluctuations and meet client demand.

• Oversee review inventory while ensuring quality and compliance standards are maintained.

⛳️ Requirements

• Possess an active, unrestricted RN license; compact license is preferred.

• Have a minimum of 3–5 years of clinical experience.

• Accumulate at least 2 years of experience in Utilization Review, Appeals, or Clinical Review.

• Exhibit strong knowledge of medical necessity criteria and payer guidelines.

• Have experience in drafting appeal letters.

• Demonstrate experience in reviewing inpatient and/or outpatient hospital claims.

• Achieve proficiency with EMRs and review platforms; familiarity with Epic is preferred.

• Display strong written clinical documentation and time management skills.

• Have experience with payer appeals related to medical necessity, no-auth, and readmissions.

• Be familiar with InterQual, MCG, or payer-specific criteria.

• Possess prior remote clinical review experience.

• Have multi-client or vendor-side experience.

• Understand Medicare, Medicaid, and commercial payer processes.

• Ability to work independently while meeting defined productivity expectations.

• Availability for weekday work and/or short-term surge support.

• Capable of completing computer-based tasks for 6–8 hours a day and managing interruptions.

• Able to occasionally lift and move materials weighing up to 20 lbs.

🏝️ Benefits

• Opportunities for professional development and personal growth.

• Remote work flexibility.

• PRN / variable hours according to inventory requirements.