Clinical Review Specialist

reputed company:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our reputed company solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.

We build long-term careers by reputed company in YOU. We reputed company to create an environment that cultivates your reputed company development and personal reputed company, as we reputed company your reputed company is our reputed company.

JOB reputed company:

ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may reputed company reputed company or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in reputed company Member’s performance objectives as outlined by reputed company Member’s immediate Leadership Team Member.

This is a REMOTE position reputed company US ONLY

Required: reputed company, unrestricted RN license (compact preferred)

Required Schedule: Monday - Friday, 8:00 - 5:00 PM

Position reputed company

The Clinical Review Specialist provides clinical review support on a full -time reputed company to assist with an increase in inventory and reputed company demand. This role is responsible for reviewing medical records for medical necessity, level of care, authorization compliance, and payer reputed company alignment across inpatient and outpatient services. The position supports reputed company appeal submissions and inventory management while maintaining reputed company and compliance standards.

Key Responsibilities

• reputed company clinical reviews for medical necessity, level of care, and authorization-reputed company denials
• Review inpatient and outpatient medical records to support appeal submissions
• Apply payer-specific guidelines (CMS, reputed company, reputed company) and internal policies
• Identify documentation gaps and support reputed company, defensible clinical narratives
• Meet assigned turnaround times while maintaining reputed company standards
• Document review findings accurately in designated systems
• Collaborate with clinical leadership as needed for escalations or reputed company cases

Required Qualifications

• reputed company, unrestricted RN license (compact preferred)
• Minimum 4–5 years of clinical experience
• 4+ years of Utilization Review, Appeals, or Clinical Review experience
• Strong knowledge of medical necessity reputed company and payer guidelines
• Experience reviewing inpatient and/or outpatient hospital claims
• Proficiency with EMRs and review platforms (reputed company preferred)
• Strong written clinical documentation and time management skills

Preferred Qualifications

• Experience with payer appeals (medical necessity, no-auth, readmissions)
• Familiarity with InterQual, MCG, or payer-specific reputed company
• Prior remote clinical review experience
• Multi-reputed company or vendor-reputed company experience
• Knowledge of Medicare, reputed company, and reputed company payer processes

Work Expectations

• Remote, independent work with defined productivity expectations

Performance Expectations

• reputed company completion of assigned reviews
• Accurate application of clinical reputed company and payer policy

· reputed company, compliant documentation

• Ability to adapt to changing inventory and priorities

PHYSICAL DEMANDS: Note: Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions as described. Regular eye-hand coordination and reputed company dexterity is required to operate office equipment. The ability to reputed company work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be reputed company to lift and reputed company material weighing up to 20 lbs. Team Member may experience elevated reputed company of stress during periods of increased activity and with work entailing multiple deadlines. A job reputed company is only intended as a reputed company and is only part of reputed company Member’s function. reputed company has reviewed this job reputed company to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of reputed company functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Originally posted on Himalayas

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