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Clinical Reviewer Jobs in Raleigh, NC (NOW HIRING)

Amerihealth Caritas

Quality Perform Spec Clinical

Raleigh, NC · On-site +1

$31.25 - $41.75/hr

Coordinates reviews with physician advisors and clinical quality committees as appropriate. * Assures minimally necessary medical records are collected and organized for clinical review to occur.

Centene

Psychologist Reviewer

Durham, NC · On-site +1

$87K - $157K/yr

You could be the one who changes everything for our 28 million members as a clinical professional ... Centene is Hiring - Remote Psychologist Reviewers (ABA) Centene is seeking Remote Psychologist ...

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All JobsClinical Reviewer JobsClinical Reviewer Jobs in Raleigh, NC

Clinical Reviewer information

See Raleigh, NC salary details

$23

$34

$45

How much do clinical reviewer jobs pay per hour?

As of Aug 20, 2026, the average hourly pay for clinical reviewer in Raleigh, NC is $34.91, according to ZipRecruiter salary data. Most workers in this role earn between $30.38 and $39.23 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.

More about Clinical Reviewer jobs

What are the most commonly searched types of Clinical Reviewer jobs in Raleigh, NC?

The most popular types of Clinical Reviewer jobs in Raleigh, NC are:

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For Clinical Reviewer jobs in Raleigh, NC, the most frequently searched job titles are:

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The top searched job categories for Clinical Reviewer jobs in Raleigh, NC are:

What cities near Raleigh, NC are hiring for Clinical Reviewer jobs?

Cities near Raleigh, NC with the most Clinical Reviewer job openings:

Clinical Reviewer jobs near you
Infographic showing various Clinical Reviewer job openings in Raleigh, NC as of August 2026, with employment types broken down into 69% Full Time, and 31% Part Time. Highlights an 85% In-person, and 15% Remote job distribution, with an average salary of $72,617 per year, or $34.9 per hour.

Clinical Review Nurse - Concurrent Review

Spectraforce Technologies

Raleigh, NC • On-site

Other

Posted 4 days ago

Job description

Position Title: Clinical Review Nurse - Concurrent Review
Work Location: Remote (Compact Nursing License Required, Central Time Zone)
Assignment Duration: 12 months (Possibility to extend or convert)
Work Schedule: Friday-Tues, 2 pm-10 pm CST, 40 hours/week.
Either five 8-hour shifts until 10 PM EST Friday-Tues,
OR four 10-hour shifts until 10 PM EST Sat-Tues
Work Arrangement: Remote

Position Summary:
Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.

Key Responsibilities:
* Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
* Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
* Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
* Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
* Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
* Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
* Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
* Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
* Collaborates with care management on referral of members as appropriate
* Performs other duties as assigned
* Complies with all policies and standards

Qualification & Experience:
* Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required.
* Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
* Knowledge of Medicare and Medicaid regulations preferred.
* Knowledge of utilization management processes preferred.

Education/Certification
Required: Required: Highschool Diploma, Nursing Degree- Associates or Above
Preferred:
Licensure
Required: Compact Nursing License-RN, LPN, LVN.
Preferred:
Years of experience required: 1+ years,
Disqualifiers: Inability to work possible weekend hours and holidays on a rotation basis as applicable or needed by business needs
Additional qualities to look for: MCO experience, specifically with Medicaid, True Care Cloud experience is a bonus, experience working remote
  • Top 3 must-have hard skills stack-ranked by importance


1
Ability to complete work independently and with minimal supervision after training.
2
Team player
3
Great organizational skills

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