State Licensed Clinical Review Specialist

Job Summary

A company is looking for a Clinical Review Specialist to evaluate hospitalizations and perform clinical case reviews.

Key Responsibilities

• Perform retrospective medical necessity reviews to assess appeal eligibility for clinical disputes and denials
• Construct and document clinical cases to support appeals using medical necessity criteria and relevant clinical facts
• Demonstrate critical thinking and independent decision-making in the clinical appeal process

Required Qualifications

• Active unrestricted RN license in at least one state within the United States
• 2-3 years of experience in writing appeal letters and clinical auditing
• 2-3 years of Utilization Review or Case Management experience within the last 5 years
• Familiarity with payer guidelines and EMR systems such as Epic, Cerner, or Meditech
• Managed care payer experience in Utilization Review, Case Management, or Appeals is a plus