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We are hiring a Clinical Review Nurse for a remote California-based opportunity focused on appeals, grievances, medical necessity review, and utilization management. This Clinical Review Nurse role is ideal for an RN with strong experience reviewing complex medical records, applying clinical guidelines, supporting accurate reimbursement decisions, and ensuring regulatory compliance in a managed care or health plan environment. If you have a background in utilization review, payment integrity, case management, InterQual, MCG, DRG validation, retrospective review, and appeals/grievances, this Clinical Review Nurse opportunity offers a strong match.

Responsibilities

• Conduct clinical review of appeals, grievances, and disputed cases involving medical necessity and level of care
• Review prospective, concurrent, inpatient, and retrospective medical records
• Apply clinical guidelines, policy, procedures, and Evidence of Coverage benefit criteria
• Evaluate denied services and prepare recommendations to uphold or overturn determinations
• Summarize complex medical information for Medical Director and external reviewer consideration
• Document clinical findings, bill audit results, and case activity in tracking systems and databases
• Identify potential quality-of-care concerns, process gaps, and service issues
• Generate written correspondence for providers, members, and regulatory entities
• Support timely case resolution in compliance with state, federal, CMS, NCQA, and managed care requirements
• Collaborate with interdisciplinary teams to improve outcomes, accuracy, and operational efficiency

If you are a Clinical Review Nurse with experience in appeals, grievances, utilization review, medical necessity, InterQual, MCG, case management, and managed care, apply today.

Qualifications

• Active, unrestricted California RN license
• Minimum 3 years of acute care clinical experience
• Minimum 2 years of appeals and grievances casework
• Strong experience in utilization review, utilization management, quality management, or payment integrity
• Experience with medical necessity review, retrospective claims review, prior authorization, denial review, or provider disputes
• Working knowledge of InterQual, MCG, Medicare, Medi-Cal, managed care, NCQA, DRG validation, and regulatory compliance
• Strong chart review, clinical auditing, documentation, and written communication skills
• Comfortable working independently in a remote, high-volume clinical review environment
  
  If you are a Clinical Review Nurse with experience in appeals, grievances, utilization review, medical necessity, InterQual, MCG, case management, and managed care, apply today.