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Clinical Nurse Reviewer Jobs (NOW HIRING)

Clinical Nurse Reviewer

Atlanta, GA · On-site

$59K - $75K/yr

Nurse Reviewer The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing ...

Clinical Nurse Reviewer

Boston, MA · On-site

$59K - $75K/yr

Nurse Reviewer The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing ...

Clinical Nurse Reviewer

Plano, TX · On-site

$59K - $75K/yr

Nurse Reviewer The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing ...

Nurse Reviewer The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Clinical Nurse Reviewer

Morristown, NJ · On-site

$59K - $75K/yr

Nurse Reviewer The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Nurse Reviewer 1 Nurse Reviewer 1 Location: This role enables associates to work virtually ... Conducts initial medical necessity clinical screening and determines if initial clinical ...

Nurse Reviewer 1 Nurse Reviewer 1 Location: This role enables associates to work virtually ... Conducts initial medical necessity clinical screening and determines if initial clinical ...

Nurse Reviewer 1 Nurse Reviewer 1 Location: This role enables associates to work virtually ... Conducts initial medical necessity clinical screening and determines if initial clinical ...

We currently have an opening for Clinical Nurse Reviewer The Clinical nurse reviewer will specifically run analysis on this line of business and review with the Regional Medical Director(s) high cost ...

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Clinical Nurse Reviewer information

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How much do clinical nurse reviewer jobs pay per hour?

As of Aug 16, 2026, the average hourly pay for clinical nurse 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 are the key skills and qualifications needed to thrive as a clinical nurse reviewer, and why are they important?

To thrive as a Clinical Nurse Reviewer, you need a solid clinical nursing background, an active RN license, and experience interpreting medical records and guidelines. Familiarity with utilization review software, electronic health records (EHRs), and knowledge of regulatory standards such as CMS or NCQA is essential. Strong analytical skills, attention to detail, and effective communication help you excel when collaborating with providers and explaining complex medical decisions. These competencies ensure accurate, compliant, and efficient case reviews that support quality patient care and organizational objectives.

What are some common challenges clinical nurse reviewers face when transitioning from bedside nursing to a utilization review role?

Clinical Nurse Reviewers often find the shift from direct patient care to a more analytical, documentation-focused position challenging. Adjusting to a non-clinical environment requires developing strong skills in medical record review, critical thinking, and written communication. Additionally, learning to interpret insurance guidelines and collaborate with interdisciplinary teams such as physicians, case managers, and insurance representatives can be a significant change. However, these challenges offer opportunities for professional growth and can broaden your expertise within the healthcare system.

How to become a clinical nurse reviewer?

To become a clinical nurse reviewer, candidates typically need a registered nurse (RN) license, relevant clinical experience, and knowledge of healthcare policies and documentation. Some roles may require a bachelor's degree in nursing (BSN) or higher, along with familiarity with medical records review and healthcare regulations. Certification in case management or healthcare quality can enhance prospects.

What is a clinical nurse reviewer?

A Clinical Nurse Reviewer is a registered nurse who evaluates medical records and clinical documentation to ensure that healthcare services provided to patients meet established guidelines, standards, and regulatory requirements. They often work for insurance companies, healthcare organizations, or government agencies, reviewing cases for medical necessity, appropriateness of care, and compliance with policies. Their role is crucial in determining coverage decisions, preventing fraud or abuse, and supporting quality improvement initiatives within the healthcare system.
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Infographic showing various Clinical Nurse Reviewer job openings in the United States as of August 2026, with employment types broken down into 3% As Needed, 72% Full Time, 17% Part Time, and 8% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $74,707 per year, or $35.9 per hour.

Clinical Nurse Reviewer

Zelis

Atlanta, GA • On-site

$59K - $75K/yr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 7 hours ago


Zelis rating

7.6

Company rating: 7.6 out of 10

Based on 11 frontline employees who took The Breakroom Quiz

154th of 244 rated software companies


Job description

Nurse Reviewer

The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records and coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest possible savings for clients.

What You'll Do:

  • Conduct routine reviews of medical records and supporting documentation for compliance with clinical guidelines and organizational standards.
  • Validate accuracy and completeness of documentation for basic cases, ensuring essential data elements are present.
  • Identify and flag missing or incomplete information; escalate unresolved issues to senior reviewers.
  • Contact medical providers via phone or email and request a review of billing inconsistencies.
  • Communicate findings clearly to internal teams, providing concise feedback on documentation gaps.
  • Maintain current knowledge of healthcare regulations, payer requirements, and organizational policies.
  • Support administrative tasks such as data entry, case tracking, and report preparation.
  • Participate in training sessions and shadow senior reviewers to develop clinical review skills.
  • Maintain personal production metrics and quality assurance scores consistently.
  • Maintain awareness of and ensure adherence to Zelis standards regarding privacy.
  • Attends company training and regularly attends local meetings (once per month).

What You'll Bring to Zelis:

  • Current/active RN License.
  • Typically has a BA or 3-5 years of experience.
  • Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents.
  • Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs preferred.
  • Familiarity with EHR systems and Microsoft Office.
  • Exceptional attention to detail and ability to follow established processes.
  • Committed to continuous learning and professional development, with a passion for improving healthcare quality and outcomes.
  • Proactive and self-motivated, with a strong sense of ownership and accountability.
  • Ability to withstand long period of computer work while utilizing multiple computer screens at one time.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

Base Salary Range

$59,000.00 - $75,050.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.

Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com.


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