Job Description

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.

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