Clinical Review Specialist

CorroHealth • TN-Remote, TN

2d • Remote

About The Position

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.

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
• Strong knowledge of medical necessity criteria and payer guidelines
• Experience reviewing inpatient and/or outpatient hospital claims
• Proficiency with EMRs and review platforms (Epic preferred)
• Strong written clinical documentation and time management skills

Nice To Haves

• DRG downgrades and clinical validation denials
• Experience with payer appeals (medical necessity, no-auth, readmissions)
• Familiarity with InterQual, MCG, or payer-specific criteria
• Prior remote clinical review experience
• Multi-client or vendor-side experience
• Knowledge of Medicare, Medicaid, and commercial payer processes

Responsibilities

• Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials, ensuring alignment with regulatory guidelines, coding standards, and clinical documentation best practices.
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed