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Clinical Reviewer Jobs in Raleigh, NC (NOW HIRING)

Worldwide Clinical Trials

Clinical Scientist

Durham, NC · On-site +1

Develop clinical data review plans for assigned studies. * Collaborate with cross-functional study team members to ensure protocol-defined variables are collected and reported accurately. * Conduct ...

ASK Consulting

Clinical Pharmacist

Durham, NC · On-site

$59 - $63/hr

Review prior authorization requests and make coverage determinations based on member benefits and clinical criteria. * Review and summarize daily utilization review data and prepare reports for ...

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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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Clinical Reviewer information

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How much do clinical reviewer jobs pay per hour?

As of Sep 12, 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?

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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 September 2026, with employment types broken down into 78% Full Time, 19% Part Time, and 3% Contract. Highlights an 86% In-person, and 14% Remote job distribution, with an average salary of $72,617 per year, or $34.9 per hour.

Clinical Review Clinician - Appeals

Raleigh, NC • On-site

Spectraforce Technologies
Recruiting and Staffing Services • 1 - 5K employees
Learn more about Spectraforce Technologiesexternal

Other

Posted 6 days ago

Job description

Position Title: Clinical Review Clinician - Appeals
Work Location: Remote (nationally sourced, preference for 1 candidate in AZ)
Assignment Duration: 6 months (Possibility to extend or convert)

Position Summary:
Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Background & Context:
Shared Services Medicare Appeals department. Team performs clinical reviews for pre-service authorization denials as well as retrospective claim denials.

Key Responsibilities:
* Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
* Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
* Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
* Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
* Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
* 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.
* Knowledge of NCQA, Medicare and Medicaid regulations preferred.
* Knowledge of utilization management processes preferred.
* Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals

License/Certification:
LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required

Working Conditions & Physical Demands (If Applicable): 8-5 EST or CST time zone-weekend rotation required.

Additional Information (If Applicable): Productivity expectations vary by platform (Prime 7 CPD, iCP 9 CPD, CenPas 20 CPD cases per day with 95% quality).

Education/Certification
Required
Preferred: : Associate in nursing, Bachelor's in nursing or higher.
Licensure
Required: RN, LPN
Preferred: LVN
  • Years of experience required
  • Disqualifiers
  • Best vs. average
  • Performance indicators

Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals
Nice to haves: Medicare Appeals Experience
Disqualifiers: Not having a valid/active RN/LPN license
Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases
Best vs. average: Productivity expectations are set based on platform.
  • Top 3 must-have hard skills
  • Level of experience with each
  • Stack-ranked by importance
  • Candidate Review & Selection


1
Utilization Management or Appeals review background (1 plus year)
2
Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
3
Retrospective claims clinical reviews (1 plus year)

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