Clinical Review & Medical Documentation Specialist - United States

**About Agents Only Technologies Inc.** Agents Only Technologies Inc. is a global workforce and operations company supporting healthcare, technology, customer experience, and professional services across multiple industries. We collaborate with organizations nationwide to deliver high\-quality operational solutions through distributed networks and structured processes. Our network of healthcare professionals supports specialized clinical review, medical documentation, utilization management, and healthcare record synthesis projects requiring strong subject\-matter expertise and familiarity with the U.S. healthcare system. **Role Overview** We are seeking experienced U.S.\-licensed healthcare professionals (RNs, MDs/DOs, HIM, or CDI Specialists) based in the United States to join our team as **Clinical Review \& Medical Documentation Specialists**. Depending on your professional background and clinical specialty, assignments focus on Utilization Management, Appeals \& Denials Preparation, or Health Information Management (HIM) Medical Record Synthesis. **Primary Areas of Focus \& Responsibilities** **1\. Utilization Review \& Prior Authorization** * Review clinical case files and medical necessity requests across specialties such as radiology, surgery, cardiology, behavioral health, sleep studies, radiation therapy, spine/orthopedics, and DME. * Apply applicable CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to determine appropriate coverage recommendations (Approve, Deny, or Request Additional Information). * Evaluate clinical documentation against medical\-necessity criteria and U.S. payer guidelines. * Identify missing documentation and formulate appropriate requests for missing clinical details. **2\. Prior Authorization \& Appeals Preparation** * Assemble complete prior\-authorization evidence packets by reviewing patient chart documentation. * Draft clear, evidence\-based physician appeal letters addressing medical necessity denials. * Research and cite relevant peer\-reviewed medical literature (including PubMed sources) to support clinical arguments. * Apply relevant CMS coverage guidelines and evidence grading to reinforce appeal submissions. **3\. Medical Record Synthesis \& CDI** * Review complex, multi\-visit patient charts and synthesize details into structured, chronological clinical summaries. * Work with structured clinical data formats, including C\-CDA XML and FHIR\-formatted records. * Identify duplicate or redundant diagnostic testing (e.g., repeated CT or MRI scans within short timeframes). * Ensure clear source\-to\-summary traceability across electronic health record (EHR) documentation using standard HIM and CDI principles. **Qualifications \& Requirements** **Required** * **U.S. Clinical Credential:** Active U.S. RN license, MD/DO degree, or formal certification in Health Information Management (RHIA/RHIT) or Clinical Documentation Improvement (CDIP/CCDS). * **Experience:** Minimum 3\+ years of direct experience in utilization management, prior authorization, denials/appeals, case management, or HIM/CDI within the U.S. healthcare system. * **Clinical Knowledge:** Working knowledge of CMS NCD/LCD coverage determinations and U.S. payer medical necessity standards. * **Skills:** Strong evidence\-based medical writing, chart review skills, and familiarity with structured clinical data formats (C\-CDA, FHIR). **Preferred** * Experience working directly with health plan/payer denials and appeals departments, Medicare, Medicaid, or commercial coverage. * Experience with peer\-to\-peer reviews or drafting formal payer appeal letters. * Professional credentials such as CPUR, ACM, RHIA, RHIT, CDIP, or CCDS. * Background in medical literature searching, evidence grading, or complex chart summarization. **Work Details** * **Employment Type:** Independent Contractor * **Location:** Remote (United States) * **Schedule:** Flexible / Project\-dependent hours **Equal Opportunity Employer** Agents Only Technologies Inc. is committed to fostering an inclusive workforce. We welcome qualified candidates from diverse backgrounds. Selection is based solely on professional qualifications, experience, and project requirements. Pay: From $15\.00 per hour Expected hours: 20\.0 per week Benefits: * Flexible schedule Work Location: Remote