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Clinical Claims Review Jobs (NOW HIRING)

Maesa

Senior Manager, Claims Substantiation

New York, NY · On-site

$110K - $130K/yr

Develop testing plans utilizing clinical, consumer, instrumental, laboratory, and expert review methodologies. * Review statistical analyses and technical reports to ensure claims are adequately ...

Texas Health Institute

$248K - $373K/yr

... and medical claims reviews. Our role is to empower providers and members with the tools and ... The Medical Director collaborates with Enterprise Clinical Services leadership and staff to ...

Hello Heart

Director, Clinical Researcher

$180K - $197K/yr

... reviewed publications, white papers, conference abstracts, and client facing evidence that support our commercial goals. You will apply your expertise in statistics, claims analysis, and clinical ...

Vaya Health

Complex Claims Clinical Reviewer (Remote)

NC · Remote

$68K - $88K/yr

... review, post-payment auditing, and provider record review. Prepayment and post-payment claims ... The Complex Claims Clinical Reviewer participates in both informal and formal appeal processes ...

Hello Heart

Director, Clinical Researcher

... reviewed publications, white papers, conference abstracts, and client facing evidence that support our commercial goals. You will apply your expertise in statistics, claims analysis, and clinical ...

Tnafp

$248K - $373K/yr

... and medical claims reviews. Our role is to empower providers and members with the tools and ... The Medical Director collaborates with Enterprise Clinical Services leadership and staff to ...

Colorado Psychiatric

$248K - $373K/yr

... and medical claims reviews. Our role is to empower providers and members with the tools and ... The Medical Director collaborates with Enterprise Clinical Services leadership and staff to ...

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Clinical Claims Review information

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$42

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

Senior Manager, Claims Substantiation

New York, NY • On-site

Maesa
Toiletries Manufacturing • 201 - 500 employees
Learn more about Maesaexternal

$110K - $130K/yr

Full-time

Medical, Life, Retirement, PTO

Posted 12 days ago

Key responsibilities

  • Lead the development, review, and approval of product claims to ensure they are truthful, supported, and compliant with regulations.

  • Evaluate marketing, packaging, and advertising claims for risk and substantiation needs, and establish claims governance policies and procedures.

  • Partner with cross-functional teams to create compliant claims strategies, develop testing plans, review substantiation data, and prepare claims dossiers for regulatory and legal purposes.

Job description

#MaesaMagic
The next gen beauty company, Maesa is transforming the industry by incubating and growing meaningful, innovative brands and making prestige beauty accessible. Maesa believes beauty ignites inspiration, creativity, imagination, and connection, sparking new ideas and possibilities, and meeting unmet consumer needs. Through best-in-class design, formulation, brand creation and marketing capabilities, Maesa delivers new, better and different products with an unsurpassed speed to market. Maesa works with a variety of retailers to create and launch brands across beauty and wellness categories. The current portfolio includes Kristin Ess, Hairitage by Mindy McKnight, Fine'ry, Being Frenshe, and Niches & Nooks among other brands. For more information, visit www.maesa.com.
We are looking for a Senior Manager, Claims Substantiation to lead the development, review, substantiation, and governance of all product claims across the company's beauty, personal care, wellness, and cosmetic portfolios. This role serves as the subject matter expert for claims compliance and substantiation, ensuring all marketing claims are truthful, adequately supported, and compliant with applicable regulations.
The Senior Manager will work closely with Product Development, R&D, Marketing, Legal, and testing partners to establish robust claims strategies to support innovation while reducing regulatory and litigation risks.
This role is based in our Manhattan office and requires 3 days per week on-site.
Key Responsibilities
Claims Strategy & Governance
  • Engage with Product Development early in the process in developing impactful and compelling claims strategies that differentiate products while maintaining compliance with regulatory requirements.
  • Lead the claims review and approval process for new product launches, line extensions, and reformulations.
  • Evaluate proposed marketing, e-commerce, social media, packaging, and advertising claims for risk and substantiation needs.
  • Establish and maintain company claims governance policies, procedures, and workflows.
  • Update and maintain centralized claims library and substantiation database.

Claims Substantiation
  • Determine appropriate substantiation requirements for product performance, sensory, consumer perception, and ingredient-related claims.
  • Develop testing plans utilizing clinical, consumer, instrumental, laboratory, and expert review methodologies.
  • Review statistical analyses and technical reports to ensure claims are adequately supported.
  • Prepare claims dossiers and substantiation files for regulatory and legal defense.
  • Partner with external laboratories, dermatologists, toxicologists, and scientific experts on claims validation
  • Lead continuous improvement initiatives to streamline claims review processes.

Regulatory Compliance
  • Ensure claims compliance with FDA, FTC, NDA and applicable global cosmetic regulations.
  • Assess claims for potential cosmetic, drug, medical device, or food classification implications.
  • Monitor warning letters, litigation trends, competitor activity, and emerging regulatory requirements related to claims.
  • Provide regulatory risk assessments and recommendations to business stakeholders.

Cross-Functional Collaboration
  • Partner with Product Development, R&D and Marketing teams to create compelling, compliant messaging.
  • Collaborate with Product Development to identify substantiation opportunities early in the innovation process.
  • Work with Legal on claim challenges, advertising reviews, and risk mitigation strategies.
  • Support retailer review submissions and customer-specific compliance requirements.

Qualifications
  • Bachelor's degree in chemistry, Biology, Cosmetic Science, or related field.
  • 10+ years of experience in cosmetic, personal care, OTC, or CPG industries.
  • 8+ years of direct experience in product claims substantiation and regulatory compliance.
  • Demonstrated experience reviewing advertising, packaging, and digital marketing claims.
  • Experience managing external testing laboratories and substantiation studies.
  • Prior leadership experience managing cross-functional projects.

Required Knowledge & Skills
  • FDA, FTC, NDA Cosmetic Regulations related to Advertising claims
  • Cosmetic vs. Drug Claim Distinction
  • Clinical, Technical and Consumer Testing Methodologies
  • Statistical Interpretation of Test Results
  • Experience with claims dossier development and documentation management.
  • Ability to communicate complex scientific and regulatory concepts to non-technical audiences.
  • Strong project management and stakeholder management skills.
  • Excellent written and verbal communication skills.

What We Offer
$110,000/yr - $130,000/yr. Exact compensation may vary based on skills, experience, and location. This position is eligible for participation in a discretionary bonus plan based on individual and company performance.
Maesa offers a variety of benefits to eligible employees. Employees can choose to enroll in health insurance coverage, wellness programs, life and disability insurance, and retirement savings plans. Through generous paid time off, a hybrid office setup, and paid leave options, Maesa encourages wellness and balance among employees.
Our Commitment to You
At Maesa, we live by our values of collaboration, curiosity, game-changing, creativity, and discipline. We believe our people and partners are a creative force that catalyzes the possibilities in beauty to break through traditional limits and discover the "new" without restriction. We prioritize creating and fostering a welcoming environment for employees, partners, ideas, approaches, and endeavors - all through a spirit of warmth and inclusivity. As set forth in Maesa's Equal Employment Opportunity policy, we do not discriminate on the basis of any protected group status under any applicable law.
Our EVP
Maesa is the next-gen beauty company, where bold ideas become beautiful brands. We ignite the dreamer and doer in each of us. We move at the speed of culture to push boundaries and redefine possibilities unleashing #maesamagic everyday. By fostering a start-up spirit, we equip everyone to lead with accountability & execute with excellence. We champion each voice and empower every journey, creating an environment where we celebrate diversity of thinking, calculated risk taking, and cutting-edge innovation. Growth is personal, intentional, and limitless.
#LI-Hybrid

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