Clinical Reviewer Jobs in the United States
Greenlife Healthcare Staffing
$45 - $50
Bronx, NY
This fully remote position involves conducting clinical reviews for Medicaid cases, ensuring compliance with state regulations, and contributing to quality improvement initiatives for a respected non-profit organization. Impactful Work: Contribute to a mission-driven organization dedicated to improving patient outcomes through quality Medicaid program oversight.
St. Luke's University Health Network
Bethlehem, PA
Stooping (bending at the waist) and crouching (stooping and bending at the knee) – required frequently in most medium jobs, Handling (grasping) – required frequently in most medium jobs , Fingering (fine manipulation) – required only occasionally in most medium jobs. Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
Campbell County Health
Gillette, WY
Our organization includes Campbell County Memorial Hospital, a 90-bed acute care community hospital in Gillette; Campbell County Medical Group, featuring nearly 20 specialty and primary care clinics—including locations in Wright and Hulett; and The Legacy Living & Rehabilitation Center, a long-term care facility. Utilizes risk mitigation strategies by assisting and supporting process improvement projects and event analysis which may include RCAs, FMEAs, investigations, and medical record reviews.
Carle Health
$29.29 - $50.38
Peoria, IL
LPHA reviewer provides behavioral health assessment, intervention, and consultation to individuals and/or groups identified as having behavioral health needs, plans treatment modalities, coordinates and follows treatment plans. Maintains records in accordance with TrilliumPlace policies, as well as state and federal oversight agencies and accreditation agencies including Joint Commission, Medicaid, Medicaid Rehabilitation Option, Illinois Department of Public Health, and Commercial Insurances.
Spectraforce Technologies Inc
$70000 - $105000
Florida City, FL
For ABA Reviewers only: Must have working knowledge of psychological assessments, diagnostic tools, and evidence-based practices specifically designed for individuals with Autism Spectrum Disorder (ASD). Authorize, direct and monitor care for behavioral health and/or substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care.
US Tech Solutions, Inc.
$42 - $48
North Chicago, IL
Critically evaluates literature, interprets complex data, writes and communicates effectively, articulates information to a variety of audiences, and effectively negotiates with counterparts from cross-divisional functional areas. 6 years of combined licensed clinical practice experience, postgraduate training, and/or postgraduate pharmaceutical industry experience with 4 years’ work experience or postgraduate training in Medical Communications or related Medical Affairs experience preferred.
US Tech Solutions, Inc.
$50 - $55
North Chicago IL, IL
Experience: The candidate should have a medical degree (MD or equivalent), clinical experience in neurology, physical medicine, or related fields, and a solid understanding of regulatory requirements for therapeutic neurotoxins. US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.
SHARP HEALTHCARE
San Diego, CA
When faced with complex situations, has knowledge of and applies the appropriate policies and procedures; Effectively evaluates ongoing workflow issues as and directs daily workload to achieve efficiency and maximize resource utilization as business needs require; Attends and participates in staff meetings or reviews staff meeting communications; Reads work related email at a minimum on assigned workdays. See Sharp HealthCare Terms & Conditions at https://www.sharp.com/patient-rights-privacy/terms-of-use.cfm and Privacy Policy at https://www.sharp.com/patient-rights-privacy/privacy-practices.cfm and SonicJobs Privacy Policy at https://www.sonicjobs.com/us/privacy-policy and Terms of Use at https://www.sonicjobs.com/us/terms-conditions.
System One
Baltimore, MD
The Clinical Medical Review Nurse conducts pre? and post?claim medical reviews of professional and institutional claims and provider appeals to determine benefit eligibility and support accurate claims adjudication. Review, research, and analyze professional and institutional claims requiring medical review, applying clinical expertise, critical thinking, and medical policy to support claims processing and adjudication.
Spring Health
$80000 - $92000
New York, NY
This role is part of the Operations Performance team - within the broader Operations Intelligence function - and will own core quality measurement, insights, and improvement loops that enable Provider Operations to deliver consistently excellent provider experiences at scale. Develop and maintain scalable quality monitoring frameworks for the Provider Operations department, including sampling strategies, QA rubrics, and calibration processes to ensure scoring consistency across reviewers and teams.
MultiCare Health System
Tacoma, WA
The Clinical Reviewer is responsible for reviewing and analyzing documentation to ensure compliance with OASIS data entry for Home Health, and for documentation in support of terminal illness for Hospice Responsibilities also include communication to clinical staff on necessary corrections required to meet regulation and to report to management any audit activity related to review. Bachelor's degree in Nursing, or obtained within five (5) years from the initial date of hire; RN with 15+ years of service or internal candidates hired before January 1, 2021 may be considered in satisfaction of this requirement in lieu of an education agreement.
MultiCare Health System
Tacoma, WA
The Surgical Clinical Reviewer works with the Manager of the Pediatric Surgery Program to implement and monitor the quality of care of pediatric patients receiving surgical services; serves as a resource for multidisciplinary team members; provides data abstraction into the ACS NSQIP-P database; participates in teams and evaluates performance improvement; develops effective working relationships with members of the Children's Surgery Department and ancillary hospital employees. MultiCare Mary Bridge Children's Hospital is the state-designated Level II Pediatric Trauma Center and the only pediatric hospital in Washington's South Sound Region dedicated to a comprehensive network of health services for children and adolescents.
Qualis Health
$37 - $45
Seattle, WA
This role conducts prospective, concurrent, and retrospective utilization management reviews to support high-quality, cost-effective care while ensuring compliance with evidence-based guidelines, regulatory requirements, and organizational policies. Evaluate requests for healthcare services using clinical review criteria, organizational policies, regulatory requirements, and evidence-based guidelines to determine medical necessity and appropriateness.
St. Luke's University Health Network
Bethlehem, PA
Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. Stooping (bending at the waist) and crouching (stooping and bending at the knee) – required frequently in most medium jobs, Handling (grasping) – required frequently in most medium jobs , Fingering (fine manipulation) – required only occasionally in most medium jobs.
Providence Health and Services
View Park-Windsor Hills, CA
See Providence Health and Services Terms & Conditions at https://www.providence.org/utility-pages/privacy-policy#terms-of-use and Privacy Policy at https://www.providence.org/utility-pages/privacy-policy#privacy-policy and SonicJobs Privacy Policy at https://www.sonicjobs.com/us/privacy-policy and Terms of Use at https://www.sonicjobs.com/us/terms-conditions. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington.
Dane Street
Rochester, NY
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to dermatology care. Dane Street is seeking experienced Board-Certified Dermatologist to join our growing team of expert clinical reviewers.
Dane Street
Indianapolis, IN
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to orthopedic care. Dane Street is seeking experienced Board-Certified Orthopedic Surgeon to join our growing team of expert clinical reviewers.
Dane Street
Everett, WA
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to orthopedic spine surgery care. Dane Street is seeking experienced Board-Certified Orthopedic Spine Surgeons to join our growing team of expert clinical reviewers.
Dane Street
Worcester, MA
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to ophthalmology care. In this role, you will apply your orthopedic expertise to conduct comprehensive reviews of clinical cases and provide objective, evidence-based medical opinions.
Dane Street
Cleveland, OH
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to occupational medicine care. Dane Street is seeking experienced Board-Certified Occupational Medicine physicians to join our growing team of expert clinical reviewers.
Dane Street
Houston, TX
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to physical medicine & rehab/pain management care. Dane Street is seeking experienced Board-Certified Physical Medicine & Rehab/Pain Management physicians to join our growing team of expert clinical reviewers.
Dane Street
Fort Worth, TX
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to psychological care. In this role, you will apply your psychology expertise to conduct comprehensive reviews of clinical cases and provide objective, evidence-based medical opinions.
Dane Street
Rockford, IL
Benefits Independent consultant role offering schedule flexibility and predictable work hours Ability to choose case types and workload based on your availability No doctor patient relationship established; no treatment is provided all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, along with ongoing support and a dedicated point of contact Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to dermatology care.
Dane Street
Oakland, CA
Benefits Independent consultant role offering schedule flexibility and predictable work hours Ability to choose case types and workload based on your availability No doctor patient relationship established; no treatment is provided all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, along with ongoing support and a dedicated point of contact Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to psychological care.
Dane Street
Santa Clara, CA
Benefits Independent consultant role offering schedule flexibility and predictable work hours Ability to choose case types and workload based on your availability No doctor patient relationship established; no treatment is provided all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, along with ongoing support and a dedicated point of contact Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to ophthalmology care.
Dane Street
Madison, WI
Benefits Independent consultant role offering schedule flexibility and predictable work hours Ability to choose case types and workload based on your availability No doctor patient relationship established; no treatment is provided all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, along with ongoing support and a dedicated point of contact Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to orthopedic spine surgery care.
Dane Street
Hartford, CT
Benefits Independent consultant role offering schedule flexibility and predictable work hours Ability to choose case types and workload based on your availability No doctor patient relationship established; no treatment is provided all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, along with ongoing support and a dedicated point of contact Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to physical medicine & rehab/pain management care.
Dane Street
Little Rock, AR
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to vascular surgery care. Dane Street is seeking experienced Board-Certified Vascular Surgeon to join our growing team of expert clinical reviewers.
Dane Street
Baltimore, MD
Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, participating in peer-to-peer discussions when appropriate, and responding to specific questions from our clients related to vascular surgery care. Dane Street is seeking experienced Board-Certified Vascular Surgeon to join our growing team of expert clinical reviewers.
CornerStone Staffing
$24000
The Colony, TX
The Pharmacy Technician supports clinical pharmacy programs by coordinating medication-related tasks and helping members navigate prescription and lifestyle resources. • Guide members through lifestyle vendor programs, resolve questions or issues, and act as a liaison between members, vendors, and clinical reviewers.
US Tech Solutions, Inc.
$60 - $61
Canton, MA
Key Responsibilities/Duties – what you will be doing Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
Kaiser Permanente
Decatur, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Decatur, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Atlanta, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Atlanta, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Kennesaw, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Atlanta, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Jonesboro, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Kaiser Permanente
Decatur, GA
The activities will include daily review of hospital care by chart review and discussion with attending physician, admission and concurrent review for inpatient admissions, meetings with patient and families to develop discharge planning, identification of patients for ambulatory case management, communication with case managers, home care reviewers, social workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Responsible for working collaboratively with physician partners to optimize quality and efficiency of care for hospitalized members by carrying out daily utilization and quality review, monitoring for inefficiencies and opportunities to improve care, developing a safe discharge plan to include recommending alternative levels and sites of care when appropriate.
Christus Health
Irving, TX
Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services.
Careers Integrated Resources Inc
$37.97
Atlanta, GA
You will work closely with members, providers, and multidisciplinary teams to coordinate integrated care and support improved member health outcomes. The Care Review Clinician is responsible for reviewing inpatient services to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations.
Kinetic Personnel Group
Ontario, CA
The HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and departments on HEDIS improvement related issues, serving as a resource for internal and external customers. A permanent position does include excellent retirement pension (CalPERS), ~10% yearly bonus, 6% contribution 453b and excellent government benefits including a generous Holiday/PTO schedule.
Qualis Health
Seattle, WA
Our Medical Affairs team, consisting of 30 physicians/dentists and a network of over 35 physician consultants, provide medical review, quality of care oversight, and consultation for various contracts with government and private sector benefit programs. Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver's license and meet the organization's driving eligibility requirements.
Qualis Health
$137 - $145
Seattle, WA
This role performs clinical reviews and appeals across multiple lines of business, including Medicaid, Workers' Compensation, and private healthcare products, applying evidence-based medicine and sound clinical judgment. This position is well suited for physicians looking for flexible, non-clinical work while maintaining an active or reduced clinical practice.
HCA Healthcare
Houston, TX
This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA).Do you have the career opportunities as a Clinical Reviewer LPN you want with your current employer? Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing.
US Tech Solutions, Inc.
$60
Canton, MA
The Clinical Reviewer, Inpatient RN provides timely, clinically appropriate and cost-effective utilization management and discharge planning activities for company’s members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Job Description: The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of members across one or more types of inpatient settings; acute, subacute, acute rehabilitation, LTAC, and others.
GreenLife Healthcare Staffing
$45 - $50
Jericho, NY
This role combines clinical expertise with analytical review, focusing on utilization reviews, quality data collection, and appeal-level determinations to support healthcare quality improvement initiatives. We partner with hospitals, clinics, nursing homes, multi-specialty groups, and private practices to match talented individuals with roles that align with their skills and career goals.
TEEMA
$85000 - $92000
phoenix, AZ
Speed is critical ? need strong pipeline immediately. Bachelor’s degree in Nursing or healthcare-related field.
Greenlife Healthcare Staffing
$100000 - $105000
New York, NY
This fully remote position involves conducting clinical reviews for Medicaid cases, ensuring compliance with state regulations, and contributing to quality improvement initiatives for a respected non-profit organization. We partner with hospitals, clinics, nursing homes, multi-specialty groups, and private practices to match talented individuals with roles that align with their skills and career goals.