Clinical Review Specialist

 About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable 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 investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

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 perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

This is a REMOTE position within US ONLY

Permanent Work Status Required

Required: Active, unrestricted RN license (compact preferred)

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

Position Summary

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

• Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials, ensuring alignment with regulatory guidelines, coding standards, and clinical documentation best practices.
• Perform clinical reviews for medical necessity, level of care, and authorization-related denials
• Review inpatient and outpatient medical records to support appeal submissions
• Apply payer-specific guidelines (CMS, Medicaid, commercial) and internal policies
• Identify documentation gaps and support clear, defensible clinical narratives
• Meet assigned turnaround times while maintaining quality standards
• Document review findings accurately in designated systems
• Collaborate with clinical leadership as needed for escalations or complex cases

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

• DRG downgrades and clinical validation denials
• Experience with payer appeals (medical necessity, no-auth, readmissions)
• Familiarity with InterQual, MCG, or payer-specific criteria
• Prior remote clinical review experience
• Multi-client or vendor-side experience
• Knowledge of Medicare, Medicaid, and commercial payer processes

• Remote, independent work with defined productivity expectations

• Timely completion of assigned reviews
• Accurate application of clinical criteria and payer policy
• Clear, compliant documentation
• Ability to adapt to changing inventory and priorities

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform 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 able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.