Clinical Review Specialist (Active, Unrestricted RN license REQD)

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.Location: Remote within US onlyPosition SummaryThe PRN Clinical Review Specialist provides clinical review support on an as-needed basis to assist with fluctuations 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.Key ResponsibilitiesPerform clinical reviews for medical necessity, level of care, and authorization-related denialsReview inpatient and outpatient medical records to support appeal submissionsApply payer-specific guidelines (CMS, Medicaid, commercial) and internal policiesIdentify documentation gaps and support clear, defensible clinical narrativesMeet assigned turnaround times while maintaining quality standardsDocument review findings accurately in designated systemsCollaborate with clinical leadership as needed for escalations or complex casesRequired QualificationsActive, unrestricted RN license (compact preferred)Minimum 3–5 years of clinical experience2+ years of Utilization Review, Appeals, or Clinical Review experienceStrong knowledge of medical necessity criteria and payer guidelinesExperience writing appeals lettersExperience reviewing inpatient and/or outpatient hospital claimsProficiency with EMRs and review platforms (Epic preferred)Strong written clinical documentation and time management skillsExperience with payer appeals (medical necessity, no-auth, readmissions)Familiarity with InterQual, MCG, or payer-specific criteriaPrior remote clinical review experienceMulti-client or vendor-side experienceKnowledge of Medicare, Medicaid, and commercial payer processesSchedule & Work ExpectationsPRN / variable hours based on inventory needsRemote, independent work with defined productivity expectationsAvailability may include weekdays and/or short-term surge supportPerformance ExpectationsTimely completion of assigned reviewsAccurate application of clinical criteria and payer policyClear, compliant documentationAbility to adapt to changing inventory and prioritiesPHYSICAL 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.Originally posted on Himalayas

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.Location: Remote within US onlyPosition SummaryThe PRN Clinical Review Specialist provides clinical review support on an as-needed basis to assist with fluctuations 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.Key ResponsibilitiesPerform clinical reviews for medical necessity, level of care, and authorization-related denialsReview inpatient and outpatient medical records to support appeal submissionsApply payer-specific guidelines (CMS, Medicaid, commercial) and internal policiesIdentify documentation gaps and support clear, defensible clinical narrativesMeet assigned turnaround times while maintaining quality standardsDocument review findings accurately in designated systemsCollaborate with clinical leadership as needed for escalations or complex casesRequired QualificationsActive, unrestricted RN license (compact preferred)Minimum 3–5 years of clinical experience2+ years of Utilization Review, Appeals, or Clinical Review experienceStrong knowledge of medical necessity criteria and payer guidelinesExperience writing appeals lettersExperience reviewing inpatient and/or outpatient hospital claimsProficiency with EMRs and review platforms (Epic preferred)Strong written clinical documentation and time management skillsExperience with payer appeals (medical necessity, no-auth, readmissions)Familiarity with InterQual, MCG, or payer-specific criteriaPrior remote clinical review experienceMulti-client or vendor-side experienceKnowledge of Medicare, Medicaid, and commercial payer processesSchedule & Work ExpectationsPRN / variable hours based on inventory needsRemote, independent work with defined productivity expectationsAvailability may include weekdays and/or short-term surge supportPerformance ExpectationsTimely completion of assigned reviewsAccurate application of clinical criteria and payer policyClear, compliant documentationAbility to adapt to changing inventory and prioritiesPHYSICAL 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.Originally posted on Himalayas