Remote RN: Clinical Review & Appeals Specialist

Santa Barbara Cottage Hospital; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Santa Barbara Cottage Hospital is seeking a PRN Clinical Review Specialist to provide remote clinical review support. You will evaluate medical necessity, level of care, and payer guidelines across inpatient and outpatient services.

The role requires an active RN license (compact preferred), 3–5 years of clinical experience, and 2+ years in Utilization Review/Appeals. Strong documentation and Epic EMR skills are expected for this remote, variable-hours position.

Qualifications

• Active, unrestricted RN license (compact preferred) and 3–5 years of clinical experience.
• 2+ years of Utilization Review, Appeals, or Clinical Review experience.
• Strong knowledge of medical necessity criteria and payer guidelines.
• Experience writing appeals letters and reviewing hospital claims.
• Proficient with EMRs and review platforms (Epic preferred).
• Strong written clinical documentation and time management skills.
• Familiarity with payer appeals processes and InterQual/MCG criteria.
• Remote clinical review experience and multi-client/vendor experience.

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 defensible clinical narratives.
• Meet turnaround times while maintaining quality standards.
• Document review findings accurately in designated systems.
• Collaborate with clinical leadership for escalations or complex cases.

Skills

RN license

Clinical experience

Utilization Review

Medical necessity guidelines

Payer appeals

Appeals letters

Medical records review

EMRs (Epic)

Documentation skills

Remote work experience

InterQual/MCG knowledge

Medicare/Medicaid knowledge

Inpatient/outpatient claims

Tools

Epic

Job description

Santa Barbara Cottage Hospital is seeking a PRN Clinical Review Specialist to provide remote clinical review support. You will evaluate medical necessity, level of care, and payer guidelines across inpatient and outpatient services.

The role requires an active RN license (compact preferred), 3–5 years of clinical experience, and 2+ years in Utilization Review/Appeals. Strong documentation and Epic EMR skills are expected for this remote, variable-hours position.