PRN Clinical Review Specialist
New
Based in the United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 4–5 years
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.
Responsibilities
- 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.
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