- Experience
- 4–5 yrs
- Salary
- —
- Openings
- 1
- Posted
- 2 days ago
- Work mode
- Work from home
- Resume
- Required to apply
Job description
About Us
We are dedicated to supporting clients in surpassing their financial health objectives. Our extensive solutions span the reimbursement cycle, combining programmatic expertise with advanced technology and analytics to drive effective clinical operations. We are committed to fostering long-term careers by prioritizing your development and growth, as we believe mutual success is integral.
Position Overview
The Clinical Review Specialist role delivers clinical review support in response to increased workload and client needs. This remote position, based in the US, requires an active, unrestricted RN license (compact preferred) and involves Monday to Friday work hours from 8:00 AM to 5:00 PM. The specialist is tasked with evaluating medical records for medical necessity, level of care, authorization compliance, and adherence to payer guidelines, across inpatient and outpatient services. The role also facilitates timely appeal submissions and manages review inventory while ensuring quality and compliance.
Key Responsibilities
- Conduct comprehensive clinical reviews focusing on medical necessity, level of care, and authorization-related denials.
- Examine both inpatient and outpatient medical records to support effective appeal processes.
- Apply payer-specific guidelines such as CMS, Medicaid, and commercial policies alongside internal protocols.
- Detect documentation deficiencies and assist in composing clear, defensible clinical narratives.
- Ensure adherence to turnaround times without compromising quality standards.
- Maintain accurate documentation of review outcomes within designated systems.
- Consult clinical leadership for escalated or complex cases as necessary.
Required Qualifications
- Possession of an active, unrestricted RN license (compact license preferred).
- At least 4 to 5 years of clinical experience.
- A minimum of 4 years experience in Utilization Review, Appeals, or Clinical Review.
- Strong understanding of medical necessity criteria and payer requirements.
- Experience assessing inpatient and/or outpatient hospital claims.
- Proficient in electronic medical records (EMRs) and review platforms; Epic familiarity preferred.
- Effective clinical documentation and time management abilities.
Preferred Qualifications
- Background in handling payer appeals including medical necessity, no authorization, and readmissions.
- Knowledge of InterQual, MCG, or other payer-specific clinical criteria.
- Prior experience working remotely in clinical review roles.
- Experience serving multiple clients or working vendor-side.
- Understanding of Medicare, Medicaid, and commercial payer policies.
Performance Expectations
- Complete clinical reviews punctually.
- Consistently apply clinical criteria and payer policies accurately.
- Produce clear, compliant documentation.
- Adapt effectively to fluctuating workloads and priorities.
Work Environment and Physical Requirements
This role requires remote, independent work with clear productivity expectations. Daily work involves extensive computer use for 6-8 hours amid potential interruptions. Reasonable accommodations are available for disabilities. Physical demands may include occasional lifting of materials up to 20 lbs and enduring periods of sitting. Elevated stress may occur during peak workload times and deadline pressures.
Additional Notes
The job description serves as a guideline outlining essential responsibilities but is not exhaustive. Additional duties may be assigned as required by supervisors to meet business needs.