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Clinical Reviewer Jobs (NOW HIRING)

Nexus Health Systems

Clinical Reviewer

Houston, TX · On-site

Clinical Reviewer Nexus Health Systems | Houston, TX | Onsite Position Summary Nexus Health Systems is seeking an experienced Clinical Reviewer to support the evaluation and admission of patients ...

Nexus Health Systems Ltd

Clinical Reviewer

Houston, TX · On-site

Clinical Reviewer Nexus Health Systems | Houston, TX | Onsite Position Summary Nexus Health Systems is seeking an experienced Clinical Reviewer to support the evaluation and admission of patients ...

Comagine

Clinical Reviewer

In this role, you will review clinical documentation to determine medical necessity and appropriateness of services, complete functional needs assessments that evaluate how mental health symptoms ...

Comagine Health

Clinical Reviewer DC

Washington, DC · On-site

The Clinical Reviewer position supports utilization management activities by assessing the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective ...

Comagine

Clinical Reviewer DC

Washington, DC · On-site

Clinical Reviewer Position Are you passionate about using your clinical expertise to support quality healthcare outcomes and ensure members receive medically appropriate services? Do you enjoy ...

Medix

Clinical Reviewer

Phoenix, AZ · On-site

$150/hr

Job Summary Our client is seeking a Clinical Reviewer for the CO SUD project starting in August 2026. The role involves conducting a utilization management overread of a percentage of residential and ...

mycenters

UM Clinical Reviewer

Pompano Beach, FL · On-site

The Utilization Management Clinical Reviewer works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their ...

Virtix Health LLC

Clinical Quality Reviewer

The Clinical Reviewer combines clinical expertise with strong analytical and documentation skills while collaborating with physicians, nurses, quality teams, customer service, and technology partners.

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Clinical Reviewer information

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How much do clinical reviewer jobs pay per hour?

As of Sep 2, 2026, the average hourly pay for clinical 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 reviewer?

Clinical reviewers are professionals who evaluate medical records, clinical data, or healthcare documentation to ensure accuracy, compliance, and quality of care. They may work in settings such as hospitals, insurance companies, or regulatory agencies to review cases for appropriateness of care, adherence to clinical guidelines, or for billing and coding accuracy. Clinical reviewers often have backgrounds in nursing, medicine, or another healthcare field and use their expertise to make informed assessments. Their work is critical for improving patient outcomes, supporting proper reimbursement, and maintaining regulatory standards.

What does a clinical reviewer do?

A clinical reviewer monitors healthcare documents to ensure compliance before submitting to insurance companies. You handle the daily responsibilities of checking medical records for appropriate criteria and providing the proper documentation. You collaborate with providers to ensure all information is accurate. Your duties are also to review requests for services, research and gather further information when necessary, perform an information audit, and evaluate procedures for approval. You also record, analyze, and report data elements that could help improve the quality of care of a patient.

What skills are required for a clinical reviewer?

To thrive as a Clinical Reviewer, you need a strong background in healthcare or life sciences, often supported by a relevant degree and experience in clinical settings. Familiarity with medical terminology, regulatory requirements, and systems such as electronic medical records (EMRs) or clinical trial management software is typical. Attention to detail, analytical thinking, and effective written communication are standout soft skills for this role. These skills ensure accurate evaluation of clinical data, compliance with standards, and clear reporting, which are critical for patient safety and regulatory approval.

What are some common challenges clinical reviewers face when evaluating medical records, and how can they be addressed?

Clinical Reviewers often encounter challenges such as incomplete documentation, inconsistent terminology, and tight deadlines when evaluating medical records. To overcome these issues, it's important to develop strong attention to detail, stay current with medical coding standards, and communicate effectively with healthcare providers to clarify ambiguities. Collaborating closely with clinical teams and leveraging electronic health record (EHR) systems can also help streamline the review process and ensure accuracy.

What is the difference between Clinical Reviewer vs Medical Reviewer?

AspectClinical ReviewerMedical Reviewer
Required CredentialsRN, LPN, or other healthcare licenses; sometimes certifications in case management or clinical reviewMD or DO; medical license; often board-certified in a specialty
Work EnvironmentInsurance companies, healthcare organizations, or government agencies; reviewing medical records and claimsHospitals, clinics, insurance companies; evaluating medical records and providing expert opinions
Employer & Industry UsagePrimarily in insurance and healthcare administrationPrimarily in insurance, healthcare, and legal settings

Both Clinical Reviewers and Medical Reviewers assess medical information, but Clinical Reviewers typically hold nursing or allied health credentials and focus on case management and claims review. Medical Reviewers are licensed physicians who provide expert medical opinions. The roles often overlap in insurance and healthcare industries, but their credentials and scope of practice differ.

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Clinical Reviewer jobs near you
Infographic showing various Clinical Reviewer job openings in the United States as of August 2026, with employment types broken down into 3% As Needed, 71% Full Time, 18% 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 Reviewer

Nexus Health Systems

Houston, TX • On-site

Other

This job post has expired today. Applications are no longer accepted.

Nexus Health Systems rating

6.3

Company rating: 6.3 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Job description

Clinical Reviewer
Nexus Health Systems | Houston, TX | Onsite
Position Summary
Nexus Health Systems is seeking an experienced Clinical Reviewer to support the evaluation and admission of patients into our specialized behavioral health, neurodevelopmental, and medically complex programs.
The Clinical Reviewer reviews medical records, clinical histories, assessments, and referral documentation to determine clinical appropriateness and program fit. This position develops thorough, high-quality clinical evaluations and summaries that support admission and authorization decisions while meeting the documentation requirements of commercial insurance, Medicaid, and other funding sources.
We are specifically seeking an experienced Registered Nurse (RN) or Nurse Practitioner (NP) with strong clinical judgment, excellent documentation skills, and experience evaluating complex patient needs. Nurse Practitioners with clinical leadership experience are strongly encouraged to apply, as this position may offer opportunities for expanded leadership responsibilities within the clinical evaluation team.
What You'll Do
Clinical Review & Evaluation
  • Review incoming referrals, medical records, clinical histories, assessments, and supporting documentation to determine clinical appropriateness and program fit.
  • Evaluate patients with behavioral health conditions, autism spectrum disorder, intellectual and developmental disabilities, and medically complex needs.
  • Assess patient acuity, clinical risk, medical necessity, and appropriateness for Nexus programs.
  • Identify missing or insufficient clinical information and obtain additional documentation necessary to complete the evaluation.
  • Develop clear, comprehensive clinical evaluations and summaries supporting admission and authorization decisions.
  • Apply sound nursing judgment and critical thinking when evaluating complex referrals.
Payer & Authorization Support
  • Prepare clinical documentation that supports medical necessity and meets commercial insurance, Medicaid, and other payer requirements.
  • Maintain knowledge of payer authorization criteria, documentation standards, regulatory requirements, and evolving funding policies.
  • Ensure clinical evaluations are accurate, complete, timely, and defensible.
  • Anticipate potential payer questions or documentation deficiencies and proactively address them during the review process.
  • Support efficient authorization and admission processes through strong clinical documentation.
Collaboration & Communication
  • Collaborate with referral sources, physicians, nursing teams, admissions staff, clinical leadership, and other interdisciplinary team members.
  • Communicate with referral sources to clarify clinical information and obtain missing documentation.
  • Clearly communicate clinical findings, concerns, and recommendations to internal stakeholders.
  • Interact professionally and compassionately with patients, families, clinicians, and referral partners.
  • Serve as a clinical resource throughout the referral and evaluation process.
Quality & Timeliness
  • Manage multiple clinical evaluations and referrals simultaneously while maintaining accuracy and attention to detail.
  • Complete reviews within established turnaround expectations to support timely admission decisions.
  • Balance speed and responsiveness with patient safety, clinical quality, regulatory compliance, and payer requirements.
  • Identify opportunities to improve clinical evaluation workflows, documentation quality, and overall efficiency.
Leadership & Continuous Improvement
  • Maintain current knowledge of behavioral health conditions, neurodevelopmental disorders, medically complex populations, payer requirements, assessment tools, and evidence-based clinical practices.
  • Participate in initiatives to improve clinical review, evaluation, and admission processes.
  • Provide clinical guidance and support to members of the admissions and evaluation teams.
  • Candidates with appropriate experience may assist with mentoring, clinical oversight, workflow development, and other leadership responsibilities within the evaluation team.
  • Partner with organizational leadership to strengthen clinical decision-making, documentation quality, and team performance.
What We're Looking For
Education
  • Registered Nurse: Bachelor's degree in Nursing (BSN) required.
  • Nurse Practitioner: Master's degree in Nursing or other accredited graduate nursing degree required.
Experience
  • Minimum of 3 years of clinical nursing experience.
  • Experience in behavioral health, autism spectrum disorder, intellectual/developmental disabilities, pediatrics, or medically complex patient populations preferred.
  • Previous experience with clinical review, utilization review, care management, admissions evaluations, medical necessity review, or similar clinical decision-making strongly preferred.
  • Experience preparing clinical documentation for insurance, Medicaid, authorization, or funding approval preferred.
  • Experience collaborating with interdisciplinary clinical teams.
  • Leadership, supervisory, or clinical team-lead experience strongly preferred for Nurse Practitioner candidates.
Licensure & Certification
  • Current, unrestricted Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN)/Nurse Practitioner license.
  • Current Texas licensure or eligibility to obtain Texas licensure required.
  • Nurse Practitioner candidates must hold appropriate national board certification applicable to their advanced practice specialty.
Skills & Attributes
  • Strong clinical judgment and critical-thinking skills.
  • Excellent written communication and clinical documentation skills.
  • Ability to interpret complex medical and behavioral health records.
  • Understanding of clinical risk, medical necessity, and appropriate levels of care.
  • Strong attention to detail and organizational skills.
  • Ability to prioritize and manage multiple referrals in a fast-paced environment.
  • Strong interpersonal and interdisciplinary communication skills.
  • Professional and compassionate communication with families, clinicians, and referral sources.
  • Proficiency with electronic medical record (EMR) and CRM systems.
  • Demonstrated leadership potential and ability to mentor or guide clinical team members.
Additional Details
  • Location: Houston, Texas
  • Work Arrangement: Onsite
  • Some schedule flexibility may be required to respond to urgent or time-sensitive referrals.

Why Nexus Health Systems?
At Nexus Health Systems, our teams care for patients with complex medical, behavioral health, and neurodevelopmental needs who often require highly specialized services. The Clinical Reviewer plays an important role in ensuring each referral receives a thoughtful, clinically sound evaluation and that patients are connected with the appropriate level of care.
For an experienced RN or Nurse Practitioner, this position offers the opportunity to apply clinical expertise beyond the bedside while directly influencing patient access, clinical decision-making, and the quality of the admissions process.

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