RN Clinical Review Specialist

Job Summary

A company is looking for a Clinical Review Specialist with an active, unrestricted RN license.

Key Responsibilities

• Perform clinical reviews for medical necessity, level of care, and authorization-related denials
• Review inpatient and outpatient medical records to support appeal submissions
• Document review findings accurately in designated systems

Required Qualifications

• Active, unrestricted RN license (compact preferred)
• Minimum 3-5 years of clinical experience
• 2+ years of Utilization Review, Appeals, or Clinical Review experience
• Strong knowledge of medical necessity criteria and payer guidelines
• Experience with payer appeals and familiarity with InterQual, MCG, or payer-specific criteria