PRN Clinical Review Specialist (Active RN License REQ'D)

📋 Description

• • Perform clinical reviews to assess medical necessity, level of care, and authorization compliance for inpatient and outpatient services across multiple payer types.
• • Review comprehensive medical records to support appeals submissions for denials, recoupments, audits, and no-auth cases.
• • Apply payer-specific guidelines including CMS, Medicaid, and commercial insurer policies alongside internal clinical review standards.
• • Identify gaps in clinical documentation and develop clear, persuasive, and defensible clinical narratives to support appeal outcomes.
• • Meet strict turnaround time expectations while maintaining high standards of accuracy and regulatory compliance.
• • Accurately document all review findings and decisions in designated electronic systems and platforms.
• • Collaborate with clinical leadership to escalate complex cases requiring additional clinical insight or policy interpretation.
• • Support fluctuating workloads as a PRN (as-needed) resource during periods of increased client demand or inventory surges.
• • Ensure all clinical reviews align with established utilization management (UM) criteria and regulatory requirements.
• • Maintain proficiency in EMR systems and clinical review platforms, with preference for experience with Epic.
• • Adapt quickly to changing priorities, evolving payer policies, and shifting case volumes without compromising quality or timeliness.
• • Operate independently in a fully remote environment with defined productivity metrics and accountability for individual output.
• • Function effectively in a high-pressure environment with frequent deadlines and constant interruptions while maintaining attention to detail.
• • Perform all duties in compliance with federal and state healthcare regulations, including HIPAA and other privacy standards.
• • Contribute to quality assurance initiatives by adhering to documented performance expectations for accuracy, timeliness, and documentation clarity.