RN Clinical Review Specialist

Job Summary

Providing clinical review support on a full-time remote basis, the RN Clinical Review Specialist will review medical records for medical necessity, authorization compliance, and payer guideline alignment, while assisting with timely appeal submissions and inventory management.

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 and collaborate with clinical leadership for escalations or complex cases

Required Qualifications

• 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