State Licensed Clinical Review Specialist

Job Summary

A company is looking for a Clinical Review Specialist to evaluate hospitalizations and perform clinical case reviews.

Key Responsibilities

• Perform retrospective medical necessity reviews to determine appeal eligibility of clinical disputes/denials
• Construct and document clinical cases to support appeals using appropriate medical necessity criteria
• Demonstrate critical thinking and independent decision-making in the clinical appeal process

Required Qualifications

• Active RN License with strong clinical knowledge in at least one state
• 2-3 years of experience in writing appeal letters and clinical auditing
• 2-3 years of Utilization Review / Case Management experience within the last 5 years
• Familiarity with payer guidelines and EMR systems like Epic, Cerner, or Meditech
• Managed care payor experience in Utilization Review, Case Management, or Appeals is a plus