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How much do clinical insurance reviewer jobs pay per hour?

As of Sep 2, 2026, the average hourly pay for clinical insurance reviewer in the United States is $35.92, according to ZipRecruiter salary data. Most workers in this role earn between $31.25 and $40.38 per hour, depending on experience, location, and employer.

What is a clinical insurance reviewer?

A Clinical Insurance Reviewer evaluates medical claims to ensure they meet insurance policies and clinical guidelines. They review patient records, verify medical necessity, and determine coverage eligibility. This role requires knowledge of medical terminology, coding, and insurance regulations. Clinical Insurance Reviewers help prevent fraud, ensure compliance, and support fair reimbursement for healthcare providers and patients.

What are the typical daily responsibilities of a clinical insurance reviewer?

Clinical Insurance Reviewers spend much of their day reviewing medical records and patient documentation to determine the medical necessity and appropriateness of treatments for insurance coverage. They assess claims against clinical guidelines, communicate their findings with healthcare providers or case managers, and may also participate in peer-to-peer reviews or appeals. Most positions involve working closely with other reviewers, physicians, and administrative staff, either remotely or in a collaborative office setting. This role requires strong organizational skills as well as the ability to manage multiple case reviews and deadlines simultaneously.

What are the key skills and qualifications needed to thrive as a clinical insurance reviewer?

To thrive as a Clinical Insurance Reviewer, you need a solid understanding of clinical practices, medical terminology, and insurance guidelines, often supported by a background in nursing or other healthcare professions. Familiarity with electronic medical records (EMRs), claims management systems, and utilization review software is highly valuable, and certifications such as Certified Professional in Healthcare Quality (CPHQ) can be advantageous. Strong analytical thinking, attention to detail, and effective communication skills set top performers apart in this role. These skills are crucial for accurately evaluating medical claims, ensuring compliance, and facilitating clear communication between healthcare providers and insurance companies.

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Clinical Insurance Reviewer jobs near you
Infographic showing various Clinical Insurance Reviewer job openings in the United States as of August 2026, with employment types broken down into 96% Full Time, and 4% Part Time. Highlights an 100% In-person job distribution, with an average salary of $74,707 per year, or $35.9 per hour.

Nurse Reviewer - Clinical Review Unit

Hawaii Medical Service Association

Kapolei, HI • On-site

Full-time

Posted 13 days ago

Job description

  1. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  2. Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
  3. Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
  4. Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
  5. Review various types of services, including but not limited to:
    • Transplants
    • Air Ambulance
    • Chemotherapy
    • Clinical trials
    • Genetic testing
    • Cancer treatments/radiation therapy
    • Experimental/Investigational Services/Devices
    • New Technology
  6. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
    • Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
    • Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
    • Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
    • Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
  7. Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  8. Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  9. Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  10. Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
  1. Associates Degree in Nursing
  2. Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN
  3. Two years clinical, case management or utilization management related experience
  4. Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
  5. Strong organizational skills
  6. Good communication skills both verbally and written
  7. Multi-tasking skills
  8. Critical thinking skills
  9. Analytical skills
  10. Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
  11. Currently licensed in Hawaii as an RN or LPN
    (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

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