• Support most complex medical record audit programs • Generate concise in-depth reporting and analysis to track performance • Provide Provider Pre Pay production and progress reports • Recommend process or procedure changes • Demonstrate leadership ability • Identify knowledge gaps and provide training opportunities • Serve as a primary resource for provider escalation support • Maintain a working knowledge of all state and federal laws, rules, and billing guidelines

Role Description Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. The West Virginia University Health System, the state’s largest health system and largest private employer, comprises 18 hospitals throughout the state and bordering states. In addition, it includes five institutes, as well as providing management services for other local hospitals through affiliate agreements. Whether you are caring for our patients at one of the critical access hospitals, community sites, regional or academic medical centers, we are all one WVU Health System. Work Here. Thrive Here. Qualifications - Scheduled Weekly Hours: 0 - Shift: Exempt/Non-Exempt - Location: United States of America (Exempt) - Company: SMG System Medical Group - Cost Center: 7994 SMG Teleradiology Multi Locations Company Description The West Virginia University Health System is the state’s largest health system and largest private employer, comprising 18 hospitals throughout the state and bordering states. - Includes five institutes - Provides management services for other local hospitals through affiliate agreements

Role Description The Clinical Review Specialist provides clinical review support on a full-time basis to assist with an increase in inventory and client demand. This role is responsible for reviewing medical records for medical necessity, level of care, authorization compliance, and payer guideline alignment across inpatient and outpatient services. The position supports timely appeal submissions and inventory management while maintaining quality and compliance standards. Essential Duties and 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 clear, defensible clinical narratives - Meet assigned turnaround times while maintaining quality standards - Document review findings accurately in designated systems - Collaborate with clinical leadership as needed for escalations or complex cases Qualifications - Active, unrestricted RN license (compact preferred) - Minimum 4–5 years of clinical experience - 4+ years of Utilization Review, Appeals, or Clinical Review experience - Strong knowledge of medical necessity criteria and payer guidelines - Experience reviewing inpatient and/or outpatient hospital claims - Proficiency with EMRs and review platforms (Epic preferred) - Strong written clinical documentation and time management skills Preferred Qualifications - Experience with payer appeals (medical necessity, no-auth, readmissions) - Familiarity with InterQual, MCG, or payer-specific criteria - Prior remote clinical review experience - Multi-client or vendor-side experience - Knowledge of Medicare, Medicaid, and commercial payer processes Work Expectations - Remote, independent work with defined productivity expectations Performance Expectations - Timely completion of assigned reviews - Accurate application of clinical criteria and payer policy - Clear, compliant documentation - Ability to adapt to changing inventory and priorities Physical Demands Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.

Role Description As a Medical Records Clerk, you ensure our digital records are complete, accurate, and easily accessible. You organize, maintain, and retrieve electronic documents with precision, supporting clinical operations and protecting the integrity and confidentiality of patient information. You’ll work closely with administrative and clinical teams to uphold high standards of documentation quality and compliance. Location: Remote within the U.S.; preference for those located in Eastern or Central time zones. Office Hours: Monday–Friday, 8am–5pm What You’ll Do - Keep the record clean, complete and organized: - Scan and index medical documents with accuracy that supports clinical and administrative workflows. - Apply consistent naming conventions so records stay structured and searchable across systems. - Maintain logs and metadata to support auditing, reporting, and workflow transparency. - Protect the data, every step: - Uphold HIPAA confidentiality and regulatory standards across all record-handling activities. - Provide authorized access to records quickly and correctly, supporting care delivery and operations. - Support documentation quality through validation, routing, and issue-spotting as records move through the system. - Be the HIM Connection Point: - Fulfill inbound record requests from patients, providers, hospitals, payors, and internal teams. - Support cross-functional information flow so data stays aligned from intake to clinical care to billing. - Support evolving HIM workflows as new processes, tools, or operational needs emerge. What Success Looks Like - Accurate, timely indexing of all incoming documents - Reliable retrieval of records with minimal turnaround time - Strong adherence to confidentiality and compliance standards - Organized, easy‑to‑navigate digital file structures - Clear communication and dependable support for internal teams Qualifications - 1–2 years of experience in medical records, administrative support, or data entry (electronic filing experience preferred) - High school diploma or equivalent - Proficiency with digital tools including Google Suite, Microsoft Office, and document management systems - Exceptional attention to detail and strong organizational skills - Ability to handle sensitive information with discretion and professionalism - Familiarity with HIPAA and records retention guidelines (preferred) - Clear communication and strong interpersonal skills - Ability to prioritize and manage time effectively - A mindset grounded in our core values: Heart, Excellence, Accountability, Resilience, and Teamwork Requirements - You have experience improving digital filing workflows - You proactively identify documentation gaps or inconsistencies - You thrive in fast‑paced, mission‑driven environments - You bring curiosity, initiative, and a commitment to operational excellence Benefits - $18-$20 per hour, based on experience and qualifications - Annual performance bonus - Health, dental, and vision insurance - Paid time off + paid sick time - 401(k) with company match