PRNClinicalReviewSpecialist

## Accountabilities Conduct clinical reviews of inpatient and outpatient medical records to determine medical necessity, level of care, and authorization compliance. Evaluate denial cases including appeals, recoupments, audits, and no-authorization determinations to support resolution strategies. Develop clear, evidence-based clinical rationales to support appeal submissions aligned with payer and regulatory guidelines. Apply payer-specific criteria (CMS, Medicaid, commercial) and internal policies to ensure accurate review outcomes. Identify documentation gaps and contribute to defensible clinical narratives for appeals and reconsiderations. Ensure timely completion of assigned reviews while maintaining accuracy, compliance, and quality standards. Document findings clearly and consistently in designated systems and collaborate with leadership on complex or escalated cases. Requirements: Active, unrestricted Registered Nurse (RN) license; compact license preferred. 4–5 years of clinical experience with a strong background in utilization review, appeals, or clinical review functions. Proven experience reviewing and resolving a wide range of denials, including medical necessity, audits, and authorization-related cases. Strong understanding of payer guidelines, medical necessity criteria, and reimbursement processes across Medicare, Medicaid, and commercial plans. Experience working with EMR systems and clinical review platforms (Epic preferred). Excellent clinical writing skills with the ability to produce clear, compliant, and persuasive appeal documentation. Strong time management and ability to work independently in a remote, PRN, productivity-driven environment. Familiarity with InterQual, MCG, or similar clinical criteria sets is highly preferred. Benefits: Flexible PRN remote schedule based on business needs and workload demand. Competitive compensation aligned with clinical expertise and experience. Opportunity to work independently in a fully remote healthcare