State Licensed Clinical Reviewer

Job Summary

Managing medical necessity denials remotely, the full-time State Licensed Clinical Reviewer will evaluate authorization requests and medical records, applying clinical knowledge and payer requirements to determine appropriate resolution paths for denials and appeals.

Key Responsibilities:

• Manage medical necessity denials from initial notification through final resolution, ensuring timely follow-up and escalation
• Review clinical documentation and payer policies to develop comprehensive, evidence-based appeals within established deadlines
• Collaborate with healthcare providers and stakeholders to determine appropriate appeal strategies and ensure compliance with regulatory standards

Required Qualifications:

• Bachelor's Degree or equivalent work experience
• Active RN License
• At least 4-6 years relevant work experience
• At least 3 years of denial management experience in an acute hospital setting
• 2 years clinical acute nursing experience