Clinical Reviewer

Role overview

This opportunity is for a Clinical Reviewer position based in the United States and supported through a partner organization that handles applications and the remaining hiring steps. The role sits within a structured healthcare review setting where careful clinical judgment, regulatory awareness, and attention to detail are essential. You will evaluate cases for medical appropriateness, help ensure determinations are accurate and timely, and work closely with providers and internal teams to keep reviews consistent with contract and compliance expectations.

The position is highly detail-driven and contributes to both quality and operational efficiency in a fast-moving environment. It requires a collaborative mindset, strong clinical expertise, and the ability to support better healthcare outcomes while meeting production and turnaround goals. The work schedule is 11:00 AM to 8:00 PM EST.

Key accountabilities

• Review clinical cases to determine medical appropriateness in line with contractual and regulatory standards.
• Deliver accurate, consistent, and timely completion of assigned reviews within established service levels.
• Organize daily assignments, call queues, and workload priorities to meet changing operational needs.
• Act as a clinical point of support for peers and assist nurse reviewers with process-related questions.
• Take part in quality monitoring activities and help identify opportunities to improve processes.
• Serve as a bridge between providers and internal teams to address issues and support service expectations.
• Work in accordance with NCQA requirements, HIPAA rules, and organizational policies.
• Participate in training and team meetings to stay current on clinical guidance and review procedures.
• Cross-train on additional contract workflows to increase flexibility and coverage.

Required profile

• Active, unrestricted LPN, RN, Social Worker, or another applicable clinical license in a U.S. state or compact state.
• Solid understanding of medical terminology, disease processes, and clinical documentation.
• Background in medical record review, abstraction, or utilization review.
• Strong clinical assessment abilities, sound judgment, and critical thinking.
• Clear written and verbal communication skills.
• Ability to manage work effectively in a structured, deadline-focused environment.
• Familiarity with case management, prior authorization, or utilization review is preferred.
• Experience in a call center or behavioral health environment is a plus.
• Bachelor’s degree in a related discipline is preferred but not mandatory.
• Bilingual English/Spanish ability is an advantage.
• Availability to work consistently from 11:00 AM to 8:00 PM EST.

Benefits and compensation

• Hourly pay range of USD 28.37 to 32.00.
• Medical, dental, and vision insurance.
• Paid time off and holiday programs.
• Retirement savings plans.
• Wellness resources and employee assistance support.
• Educational support and professional development opportunities.
• Employee discounts and support resources.
• Structured review environment with clear procedures and training.
• Chance to contribute to improved healthcare outcomes across the country.
• Stable weekday schedule from 11:00 AM to 8:00 PM EST.

Additional information

This role is supported by an AI-assisted matching process that helps surface applications for review against the core role requirements. The hiring partner receives the shortlist and manages interviews, assessments, and final decisions internally.

Data privacy and hiring process notice

By applying, you consent to the processing of your personal data for candidate evaluation and sharing with the hiring employer under applicable data protection laws, including GDPR where relevant. You may request access, correction, deletion, or objection to processing at any time.

AI tools may be used to assist with parts of the hiring workflow, such as resume review, response analysis, or identifying potential inconsistencies or verification signals in submitted materials. These tools support the recruitment team and do not replace human judgment; final hiring decisions are made by people.