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Clinical Review Nurse - Concurrent Review

Spectraforce Technologies

United States, North Carolina, Raleigh

500 West Peace Street (Show on map)

Aug 14, 2026

Job Title: Clinical Review Nurse - Concurrent Review

Location: Remote -Anywhere in US

Shift : Tuesday - Thursday 9:30 am - 6 pm CST / Overtime may be required and Holidays are required

Duration : 12 months

Position Purpose:

Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement.

Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards
Contributes to correspondence letter template creation and maintenance with the correspondence team
Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims
Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner
Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented
Coordinates with interdepartmental teams on training needed within the utilization management team based on trends
Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned
Complies with all policies and standards

Candidate Requirements
Education/Certification	Required: Requires graduated from an accredited school of nursing or A.D. or bachelor's in nursing	Preferred: 2-4 years of related experience
Licensure	Required: LPN or RN, active in any state	Preferred: Compact
Years of experience required: Must haves: Minimum 1 year nursing experience. Live anywhere in the U.S. Nice to haves: Knowledge of Medicare and Medicaid regulations; Knowledge of utilization management Disqualifiers: Performance indicators: Metric driven in production and quality
Top 3 must-have hard skills stack-ranked by importance	1	Ability to critically think
2	Ability to effectively use Microsoft OneNote and Word
3	Ability to work remotely, i.e. meet production deadlines; quality metrics