Clinical Data Services Representative RN Certified

Position Summary

Seeking a Registered Nurse (RN) with experience in Long-Term Care (LTC), Medicaid, Utilization Review, or Clinical Documentation Review to support medical necessity reviews and provider/customer inquiries in a remote environment. The role requires strong clinical judgment, documentation skills, and the ability to manage reviews, calls, and administrative tasks efficiently.

Key Responsibilities

• Conduct medical necessity reviews for LTC and Medicaid-related submissions.
• Review clinical records, assessments, and supporting documentation.
• Apply nursing knowledge and Medicaid guidelines to make review decisions.
• Investigate provider complaints, appeals, and support Fair Hearings.
• Handle provider/customer calls and resolve inquiries professionally.
• Maintain accurate documentation and case records.
• Collaborate with team members and participate in cross-training activities.

Required Qualifications

• Active, unrestricted Texas RN license.
• Experience in LTC, Medicaid, Utilization Review/Management, or Clinical Review.
• Strong analytical, critical-thinking, and problem-solving skills.
• Excellent written, verbal, and customer service skills.
• Experience reviewing clinical documentation and medical necessity criteria.
• Comfortable working in a phone-based, remote environment.
• Proficient with computer systems and healthcare applications.
• Ability to manage multiple priorities while maintaining accuracy.