12 Results for

Clinical Reviewer Jobs in North Carolina

Jobs

Charlotte, NC30+ days ago

Remote

Full-time

Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources.

NC30+ days ago

$26.01–$74.78 Per Year

Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Charlotte, NC30+ days ago

Remote

Full-time

o Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs. Technical Skills: General knowledge of Medicare, Veterans Administration, or other government health care programs; knowledge in the application of clinical criteria: InterQual, Milliman, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel.

New!

Raleigh, NC1 day ago

Remote

Part-time

With a global footprint across four continents, MMS not only maintains an industry-leading customer satisfaction rating but also fosters a collaborative and inclusive work environment where employees can thrive. Responsible for strategies in pre and post marketing risk management, as well as keeping abreast of pharmacovigilance methods and trends in published literature and global regulations.

Charlotte, NC30+ days ago

Remote

Full-time

Proficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.

New!

NC3 days ago

Where the regrouped 'new DRG' differs from what was originally claimed by the provider, write a customer facing 'rationale' or 'findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

Charlotte, NC30+ days ago

Remote

Full-time

Proficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. This role will serve as a SME and will collaborate with Claims leadership, Training, the Claims Content Specialist, and internal business partners to ensure procedures and training materials are accurate and complete.

New!

Durham, NC2 days ago

$59,829–$99,960 Per Year

In the Bellwether Collaborative for Health Justice, we look for a diverse pool of applicants including those from historically marginalized groups - people with histories of incarceration, people with disabilities, women, people who are lesbian, gay, bisexual, transgender, gender non-conforming, people with lived experiences of addiction and mental health conditions, people of color, first and second generation college students, first and second generation immigrants, rural backgrounds, veterans, and people from different socioeconomic backgrounds. Interpersonal Skills: The hired candidate will build successful, respectful, collaborative relationships with participants, community partners, and institutional stakeholders (e.g., community-based organizations, healthcare providers, and criminal legal system partners), using culturally responsive and trauma-informed approaches.

New!

Cary, NC2 days ago

Remote

$65,000–$75,000 Per Year

Location: Remote (Eligible in Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming). This role applies clinical expertise, regulatory knowledge, and critical thinking to support high-quality, compliant care decisions while collaborating with providers and internal teams.

Morrisville, NC30+ days ago

All Jobs - 6 minutes Recommended Jobs Field Reimbursement Manager Field Reimbursement Manager Field Reimbursement Manager Specialty Sales Representative Experienced Project Manager - Full-Service Share this job Apply Inside Syneos Health Our Values Who We Are Our Solutions Diversity, Equity, and Inclusion Why Work Here Discover what our more than 29,000 employees already know. Interacts and builds good working relations with clients, department head, and peers in data management, biostatistics, regulatory affairs, and medical affairs as necessary to produce writing deliverables.

New!

Kinston, NC5 days ago

$32.48–$38.98 Per Hour

To accomplish these goals, the UR, Nurse applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the care team. Responsibilities: Patients/Families, Hospital staff, Medical staff, Community agencies, and Insurance Companies are served by conducting interpersonal relationships in a manner that projects a positive image of the department and hospital.

Morganton, NC10 days ago

Youll love working with us because: We are a teaching hospital We work together to ensure our patients receive outstanding, holistic care Your expertise and ideas are valued Your health and well-being matter And much more I love working atUNCHealth Blue Ridge because I know I am seen and valued. This position collects internal and required regulatory related quality data (i.e., Centers for Medicaid and Medicare Services (CMS) and The Joint Commission (TJC) quality measures) to support ongoing, evidence-based quality and performance improvement initiatives.

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Clinical Reviewer Jobs in North Carolina

Utilization Clinical Reviewer TriWest Healthcare Alliance

Prior Authorization Clinical Reviewer CVS Health Corp

Clinical Quality Reviewer TriWest Healthcare Alliance

Cardiology Medical Reviewer (Project-Based) - Remote MMS

Claims Reviewer TriWest Healthcare Alliance

Inpatient DRG Reviewer-3 Zelis Healthcare, Inc.

Sr Claims Reviewer TriWest Healthcare Alliance

CLINICAL RESEARCH COORDINATOR Duke University

Remote Utilization Management/Review Nurse Zp Group Llc

Senior Medical Writer - Regulatory Documents - CSR /Protocol - Late Phase Syneos Health Inc

Utilization Review Nurse UNC Health

Quality Peer Review Nurse Coordinator Carolinas HealthCare System Blue Ridge

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