Clinical Reviewer
New
Based in the United States, 11:00 AM to 8:00 PM ESTFull-Time
Salary28.37 - 32 USD per hour
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Job Details
- Required Skills
- HIPAA
Requirements
- 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
- Ability to work consistently within the required 11:00 AM – 8:00 PM EST schedule
Responsibilities
- 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
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