Clinical Reviewer

Clinical Reviewer

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Reviewer based in the United States.

This role plays a key part in ensuring the medical appropriateness and quality of clinical determinations within a structured, regulated healthcare review environment. You will apply clinical judgment, critical thinking, and regulatory knowledge to evaluate cases and support accurate, timely decision-making aligned with contract and compliance requirements. The position involves direct interaction with clinical workflows, provider communication, and coordination with internal teams to ensure consistency and quality across reviews. You will contribute to maintaining high standards of accuracy while supporting production and turnaround expectations in a fast-paced setting. This is a highly detail-oriented role where clinical expertise directly supports better healthcare outcomes and operational efficiency. The environment is collaborative, mission-driven, and aligned with national healthcare quality standards. The role operates on an 11:00 AM to 8:00 PM EST schedule.

Accountabilities:

In this role, you will apply clinical knowledge and regulatory understanding to support accurate, compliant, and timely medical review processes. Your responsibilities include:

• Conducting clinical reviews to assess medical appropriateness in accordance with contract and regulatory requirements
• Ensuring accuracy, consistency, and timeliness of all assigned case reviews within established service standards
• Managing daily workload, call queues, and review assignments while adjusting priorities to meet operational demands
• Serving as a clinical resource for peers and supporting nurse reviewers with process-related questions
• Participating in quality monitoring activities and supporting identification and implementation of process improvements
• Acting as a liaison between providers and internal teams to resolve issues and support customer service needs
• Maintaining compliance with NCQA standards, HIPAA regulations, and organizational policies
• Attending training sessions and meetings to stay current on clinical guidelines and review procedures
• Cross-training on additional contract workflows to support workforce flexibility and coverage needs

Requirements:

This role requires strong clinical expertise, regulatory awareness, and excellent communication skills to support healthcare review processes. Ideal candidates should have:

• Active, unrestricted LPN, RN, Social Worker, or other applicable clinical license in a U.S. state or compact state
• Strong understanding of medical terminology, disease processes, and clinical documentation
• Experience with medical record review, abstracting, or utilization review processes
• Strong clinical assessment, critical thinking, and decision-making skills
• Excellent written and verbal communication abilities
• Ability to manage workload effectively in a structured, deadline-driven environment
• Familiarity with case management, prior authorization, or utilization review (preferred)
• Experience in a call center or behavioral health setting (a plus)
• Bachelor's degree in a related field (preferred but not required)
• Bilingual English/Spanish skills (a plus)
• Ability to work consistently within the required 11:00 AM – 8:00 PM EST schedule

Benefits:

• Competitive hourly compensation: USD $28.37 – $32.00 per hour
• Comprehensive health insurance plans (medical, dental, and vision)
• Paid time off and holiday programs
• Retirement savings plans
• Corporate wellness and employee assistance programs
• Educational assistance and professional development opportunities
• Corporate discounts and employee support resources
• Fully structured clinical review environment with clear processes and training support
• Opportunity to contribute directly to improving healthcare outcomes nationwide
• Stable weekday schedule (11:00 AM – 8:00 PM EST)