State Licensed Clinical Review Specialist

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 assess appeal eligibility for clinical disputes and denials

Construct and document clinical cases to support appeals using medical necessity criteria and relevant clinical facts

Demonstrate critical thinking and independent decision-making in the clinical appeal process

Required Qualifications

Active unrestricted RN license in at least one state within the United States

2-3 years of experience in writing appeal letters and clinical auditing

2-3 years of Utilization Review or Case Management experience within the last 5 years

Familiarity with payer guidelines and EMR systems such as Epic, Cerner, or Meditech

Managed care payer experience in Utilization Review, Case Management, or Appeals is a plus