Clinical Review Specialist

CorroHealth • FL-Remote, FL

3d • Remote

About The Position

The Clinical Review Specialist provides clinical review support on a full-time basis to assist with an increase 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.

Requirements

• Active, unrestricted RN license (compact preferred)
• Minimum 4–5 years of clinical experience
• 4+ years of 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

• 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

• 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