PRN Clinical Review Specialist

PRN Clinical Review Specialist

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a PRN Clinical Review Specialist based in the United States.

This role provides on-demand clinical review support within a fast-paced healthcare reimbursement environment, helping ensure accuracy, compliance, and timeliness in medical necessity determinations and appeal processes. You will review complex medical records across inpatient and outpatient settings to assess appropriateness of care, authorization compliance, and payer policy alignment. The position plays a critical role in supporting appeals workflows by developing clear, defensible clinical rationales that meet regulatory and payer requirements. You will work independently in a remote setting, managing variable workloads based on client demand and inventory needs. A key focus of the role is ensuring high-quality clinical documentation and adherence to strict turnaround times in a performance-driven environment. You will collaborate with clinical leadership on complex cases while maintaining consistency across multiple payer guidelines and criteria sets. This is a flexible PRN opportunity suited for experienced clinical professionals who thrive in autonomous, detail-oriented work.

Accountabilities:

• Conduct clinical reviews of inpatient and outpatient medical records to determine medical necessity, level of care, and authorization compliance.
• Evaluate denial cases including appeals, recoupments, audits, and no-authorization determinations to support resolution strategies.
• Develop clear, evidence-based clinical rationales to support appeal submissions aligned with payer and regulatory guidelines.
• Apply payer-specific criteria (CMS, Medicaid, commercial) and internal policies to ensure accurate review outcomes.
• Identify documentation gaps and contribute to defensible clinical narratives for appeals and reconsiderations.
• Ensure timely completion of assigned reviews while maintaining accuracy, compliance, and quality standards.
• Document findings clearly and consistently in designated systems and collaborate with leadership on complex or escalated cases.

Requirements:

• Active, unrestricted Registered Nurse (RN) license; compact license preferred.
• 45 years of clinical experience with a strong background in utilization review, appeals, or clinical review functions.
• Proven experience reviewing and resolving a wide range of denials, including medical necessity, audits, and authorization-related cases.
• Strong understanding of payer guidelines, medical necessity criteria, and reimbursement processes across Medicare, Medicaid, and commercial plans.
• Experience working with EMR systems and clinical review platforms (Epic preferred).
• Excellent clinical writing skills with the ability to produce clear, compliant, and persuasive appeal documentation.
• Strong time management and ability to work independently in a remote, PRN, productivity-driven environment.
• Familiarity with InterQual, MCG, or similar clinical criteria sets is highly preferred.

Benefits:

• Flexible PRN remote schedule based on business needs and workload demand.
• Competitive compensation aligned with clinical expertise and experience.
• Opportunity to work independently in a fully remote healthcare environment.
• Exposure to diverse payer types, complex cases, and advanced clinical review processes.
• Professional growth within utilization review, appeals, and revenue cycle operations.
• Supportive clinical leadership structure for escalations and case guidance.
• Dynamic workload environment with varied and intellectually engaging case types.
• Equipment and systems access provided for remote work performance.