Clinical Review Specialist (Active, Unrestricted RN license REQD)

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.

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 only Position Summary The 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.

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 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.