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 preparing high-quality appeals and managing inventory to meet client demand.

Key Responsibilities

• Prepare and submit appeals related to DRG downgrades and clinical validation denials in compliance with regulatory guidelines
• Conduct clinical reviews for medical necessity and authorization-related denials across inpatient and outpatient services
• Document review findings accurately 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 experience in DRG, Utilization Review, Appeals, or Clinical Review
• Strong knowledge of medical necessity criteria and payer guidelines
• Experience with EMRs and review platforms, preferably Epic