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Clinical Claims Review Jobs (NOW HIRING)

Acentra Health

Medical Claims Reviewer

Portland, OR · On-site

... clinical expertise. Our mission is to innovate health solutions that deliver maximum value and ... Review claims, medical records, billing, and supporting documentation prior to payment to make ...

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Clinical Claims Review information

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How much do clinical claims review jobs pay per hour?

As of Sep 12, 2026, the average hourly pay for clinical claims review in the United States is $24.12, according to ZipRecruiter salary data. Most workers in this role earn between $18.27 and $27.40 per hour, depending on experience, location, and employer.

What is clinical claims review?

Clinical claims review is the process where healthcare professionals evaluate medical claims submitted by providers to ensure they are accurate, medically necessary, and compliant with insurance policies and regulations. This involves reviewing patient records, treatment plans, and billing codes to verify that the services billed align with the care provided. The goal is to detect errors, prevent fraud, and ensure appropriate reimbursement for healthcare services.

What are the key skills and qualifications needed to thrive as a clinical claims review specialist, and why are they important?

To thrive as a Clinical Claims Review specialist, you need a solid understanding of medical terminology, coding standards (such as ICD-10 and CPT), and healthcare regulations, often supported by a background in nursing or healthcare administration. Familiarity with claims management software, electronic health records (EHRs), and relevant certifications like Certified Professional Coder (CPC) are typically required. Attention to detail, analytical thinking, and strong communication skills are essential for accurately assessing claims and collaborating with providers. These abilities ensure precise claims evaluation, reduce errors, and help maintain compliance with regulatory standards.

What are some common challenges faced by professionals in clinical claims review, and how can they be managed?

Professionals in Clinical Claims Review often encounter challenges such as interpreting complex medical records, staying updated with ever-changing insurance policies, and managing high volumes of claims within tight deadlines. Effective time management, ongoing education, and collaboration with both clinical and administrative teams are essential for success. Utilizing technology and maintaining open communication with healthcare providers can also help ensure accuracy and efficiency in the review process.

What is the difference between Clinical Claims Review vs Medical Claims Processing?

AspectClinical Claims ReviewMedical Claims Processing
CredentialsCertifications like CPC, CCS, or RHIT often preferredCertifications like CPC or CPC-H common
Work EnvironmentHealthcare settings, insurance companies, third-party administratorsInsurance companies, healthcare providers, billing departments
Job FocusEvaluating medical necessity, accuracy, and compliance of claimsData entry, coding, and processing of claims for payment

Clinical Claims Review involves assessing the medical necessity and accuracy of claims, often requiring clinical knowledge and certifications. Medical Claims Processing focuses on data entry and coding to facilitate claim payments. While both roles work within the insurance and healthcare industry, Clinical Claims Review emphasizes clinical evaluation, whereas Medical Claims Processing centers on administrative processing.

What cities are hiring for Clinical Claims Review jobs?

Cities with the most Clinical Claims Review job openings:

What states have the most Clinical Claims Review jobs?

States with the most job openings for Clinical Claims Review jobs include:

What are popular job titles related to Clinical Claims Review jobs?

For Clinical Claims Review jobs, the most frequently searched job titles are:

Clinical Claims Review jobs near you

Utilization Management Claims Review Nurse RN II

Los Angeles, CA • On-site

L.A. Care Health Plan
Health Care and Social Assistance • 1 - 5K employees
Learn more about L.A. Care Health Planexternal

$115K - $142K/yr

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 15 days ago

L.A. Care Health Plan rating

8.6

Company rating: 8.6 out of 10

Based on 11 frontline employees who took The Breakroom Quiz

Job description

Salary Range:  $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards.

This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA).

The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. 

Duties
Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation.   Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered.   Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination.   Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards.   Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols.   Collaborate with internal teams to support payment integrity initiatives.   Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions.   Maintain productivity and quality standards consistent with departmental expectations.   Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability.   Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements.

Perform other duties as assigned.

Duties Continued
Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience

Required:

At least 5 years of experience in Clinical Nursing.

At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.

Experience in performing and creating clinical documentation.

Experience in regulatory compliance for a health plan.

Preferred: 

Experience with Provider Dispute Review (PDR) processes.

Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes.

Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.

Skills

Required:

Knowledge of medical necessity criteria, reimbursement principles, and managed care operation.

Working knowledge of clinical policies.

Working knowledge of CPT/HCPC Codes, and ICD-10.

Proficient in claims processing systems and electronic medical record platforms.

Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions.

Strong verbal and written communication skills.

Ability to work independently with a high degree of initiative, organization, and self-direction.

Ability to work effectively with diverse teams in cross-functional work groups.

Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.

Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA).

Understanding of the managed care industry and market conditions.

High organizational and time-management skills.

Preferred:

Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued.

Advanced knowledge of medical necessity criteria tools such as InterQual or MCG.

Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations.  

Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.  The range is subject to change.

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

What L.A. Care Health Plan employees say

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