Clinical Review Specialist - Remote | WFH

We are seeking a Clinical Review Specialist responsible for conducting thorough clinical reviews and interpreting medical records and claim documentation to support the appeals process for denied insurance claims. This position involves drafting appeal letters based on clinical expertise and judgment. This role is remote with the option for occasional in-office work if desired by the candidate. Additionally, there may be opportunities to lead in-person training sessions with advance notice.

Hours

This is initially a part-time position (15 hours per week) with the potential to transition to full-time based on workload and availability.

Responsibilities

Review various types of hospital documentation including medical records, UB-04s, EOBs, itemized bills, and hospital account notes.

Utilize TimeMatters to manage work assignments and communicate claim notes effectively.

Interpret medical records and claim documentation to formulate appeals for denied insurance claims related to inpatient and outpatient services.

Apply clinical knowledge and judgment to assess medical necessity, admission criteria, and other clinical reviews.

Draft, review, and revise appeal letters ensuring clarity, logic, and compliance with guidelines.

Ensure all required attachments are included with each appeal and verify page number citations align with the medical record.

Handle high-priority cases within designated deadlines.

Submit appeals, follow-ups, and other documentation within timely filing periods.

Adhere to HIPAA and other regulatory compliance standards.

Contribute to the development of clinical training materials and participate in training sessions for other staff members.

Required Qualifications

Bachelor's degree from a four-year college or university.

Licensed as a Registered Nurse (RN, APRN, CRNP), Nurse Practitioner (CNP, LNP, NPC), Physician Assistant, Physician, or another qualified healthcare provider.

Compensation

Active licensure is preferred but not required.

Compensation starts at $45+ per hour depending on qualifications.

Eligibility for monthly bonuses after 90 days of employment.

Potential benefits package including 401k, health insurance, disability insurance, and commuter benefits upon transition to full-time status.

Employment Type: Part-Time