Clinical Review Specialist

Key Responsibilities:

• Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials.
• Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
• Review inpatient and outpatient medical records to support appeal submissions.

Requirements:

• Active, unrestricted RN license (compact preferred).
• Minimum 4–5 years of clinical experience.
• 4+ years of DRG, Utilization Review, Appeals, or Clinical Review experience.

Work Expectations:

• Remote, independent work with defined productivity expectations.
• Timely completion of assigned reviews.
• Accurate application of clinical criteria and payer policy.

Physical Demands:

• Regular eye-hand coordination and manual dexterity to operate office equipment.
• Ability to work at a computer terminal for 6-8 hours a day.
• Subject to sitting for prolonged periods and occasional lifting up to 20 lbs.