RN Clinical Review Specialist

Job Summary

Providing clinical review support on an as-needed basis, the part-time PRN Clinical Review Specialist will review medical records for medical necessity, level of care, and authorization compliance while ensuring timely appeal submissions and maintaining quality standards in a remote environment.

Key Responsibilities

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