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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.

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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 Jul 27, 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 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.

How much does a clinical data reviewer make?

A clinical data reviewer typically earns between $50,000 and $80,000 annually, depending on experience, location, and the employer. The role often requires familiarity with electronic data capture systems and attention to detail, with some positions offering additional benefits or bonuses.

What does a clinical reviewer do?

A clinical reviewer evaluates medical records, treatment plans, and patient data to determine coverage, compliance, and medical necessity for insurance claims or healthcare programs. They often work with healthcare providers and use clinical guidelines to ensure accurate and consistent assessments, typically requiring knowledge of medical terminology and documentation 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 are the key skills and qualifications needed to thrive as a Clinical Reviewer, and why are they important?

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 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.

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. Many employers prefer candidates with experience in case review, medical records, or healthcare compliance, and some roles may require certification such as Certified Case Manager (CCM) or similar credentials.

What are clinical reviewers?

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.

How to become a clinical data reviewer?

To become a clinical data reviewer, candidates typically need a bachelor's degree in a health-related field such as nursing, pharmacy, or life sciences. Relevant experience in clinical research, data management, or regulatory environments is often required, along with knowledge of clinical trial protocols and data analysis tools like EDC systems. Certifications such as Certified Clinical Data Manager (CCDM) can enhance job prospects.
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:
What are popular job titles related to Clinical Reviewer jobs in Raleigh, NC? For Clinical Reviewer jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Clinical Reviewer jobs in Raleigh, NC look for? 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 July 2026, with employment types broken down into 73% Full Time, and 27% Part Time. Highlights an 87% In-person, and 13% Remote job distribution, with an average salary of $72,617 per year, or $34.9 per hour.
Medicare Clinical Appeals Reviewer III

Medicare Clinical Appeals Reviewer III

St. George Tanaq Corporation

Raleigh, NC • On-site

Other

Posted 14 days ago

Job description

Medicare Clinical Appeals Reviewer III

Fully Remote-United States

Job Type

Full-time

Description

Overview

Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.

About the Role

We are seeking a Medicare Clinical Appeals Reviewer III (Dispute Resolution Reviewer III) to support our federal client. The Medicare Clinical Appeals Reviewer III is a licensed clinician who independently evaluates complex Medicare appeals and dispute cases, reviews clinical documentation, interprets federal regulations, and issues appeal determinations supported by medical evidence and policy.

They will also provide independent second-level determinations and dispute resolutions based on documentation, facts, laws, regulations, and applicable guidelines. This role works under general supervision with moderate latitude for initiative and independent judgment.

This is a remote position. Candidates must be based in the United States and able to work Eastern, Central, or Mountain Time Zone business hours.

Required: Active, unrestricted license in good standing as an RN, PT, RT, OT, or other qualifying licensed healthcare professional. Licenses with restrictions or encumbrances are not eligible.

Responsibilities

  • Review the medical records/case file, write a reconsideration/dispute resolution decision that is clear, concise, and impartial, supports the determination made, and documents the review.

  • Make fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures.

  • Respond to and ensure that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.

  • Conduct research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to make an accurate, well-supported decision.

  • Stay abreast of changes in regulations, medical and healthcare practices, policies, and procedures.

  • Participate in case-specific verbal discussions.

  • Conduct reviews of appeals/disputes involving multiple beneficiaries/services in a single case.

  • Plan responses to statistical analysis challenges with assistance from statisticians.

  • Attend meetings and participate in workgroups at management's direction.

  • Serve as a subject matter expert.

  • Mentors and/or trains staff.

  • Conduct quality reviews and audits, as needed.

  • Participate in special projects and perform other duties as assigned.

Requirements

Required Experience and Skills

  • Must have 2-3 years of experience in medical dispute resolution, Medicare appeals, medical review, clinical review, or a related healthcare setting.

  • Must have Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience. Licensed candidates with closely related clinical or medical experience may be considered.

  • Demonstrated experience writing or making appeal or payment determinations

  • Experience using Microsoft 365, including Excel and Word.

  • Must be able to pass Federal and state criminal background checks, as required by client.

  • Must be able to pass education, certification and license verification, as well as other professional background checks, as required by client.

  • Must be able to pass drug screen, as required by client.

  • Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.

Preferred Qualifications

  • Medicare appeals, medical review, healthcare compliance review, or independent dispute resolution.

  • Experience making determinations on appeals, payments, billing, or dispute resolution.

  • Experience working with or supporting a federal public health agency environment.

  • Patient-Provider Dispute Resolution or Independent Dispute Resolution experience.

  • Coding certification.

Education and Training

  • Must be an actively licensed healthcare professional with Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or closely related clinical experience.

Physical Requirements

  • Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.

Who We Are

Tanaq Support Services (TSS) is a public health contractor and certified 8(a) business owned by St. George Tanaq Corporation, an Alaska Native Corporation (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to develop effective solutions.

Our commitment to non-discrimination

Tanaq Support Services is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, protected veteran status, or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-Free Workplace Act of 1988 and participates in E-Verify.

If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.

Notice on candidate AI usage

Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills, and education. To protect the integrity of the interview process, candidates may not use artificial intelligence (AI) tools to generate or assist with responses during phone, in-person, or virtual interviews. Candidates who require a reasonable accommodation that may involve AI must contact us before their interview at accommodation@tanaq.com.

To view this and all our job postings, visit us at:

https://recruiting.paylocity.com/recruiting/jobs/All/a4712c9f-f074-40e8-9a14-bee06660bd81/Tanaq-Support-Services-LLC

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