Case Reviewer - NP/PA
Miami, FL · On-site
Conducts initial medical necessity clinical screenings. * Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a ...
Case Reviewer - NP/PA
Miami, FL · On-site
Conducts initial medical necessity clinical screenings. * Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a ...
Registered Nurse-Initial Clinical Reviewer (prior UM Health Plan experience)- Remote
Phoenix, AZ · On-site
Qualifications REQUIRED QUALIFICATIONS Required Work Experience * 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education
Registered Nurse-Initial Clinical Reviewer (prior UM Health Plan experience)- Remote
Phoenix, AZ · On-site
Qualifications REQUIRED QUALIFICATIONS Required Work Experience * 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education
Qualifications REQUIRED QUALIFICATIONS Required Work Experience * 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education
Qualifications REQUIRED QUALIFICATIONS Required Work Experience * 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education
Initial and ongoing care coordination across all providers as patients transition through the ... review, and analysis of clinical data, metrics, and quality information. * Support program ...
Initial and ongoing care coordination across all providers as patients transition through the ... review, and analysis of clinical data, metrics, and quality information. * Support program ...
Utilization Review Registered Nurse
Rockford, IL · On-site +1
$57K - $62K/yr
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to ...
Utilization Review Registered Nurse
Rockford, IL · On-site +1
$57K - $62K/yr
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to ...
Utilization Review Registered Nurse
$57K - $62K/yr
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to ...
Utilization Review Registered Nurse
$57K - $62K/yr
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to ...
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Clinical Review Medical Director - Neurology - Remote
Boston, MA · Remote
$248K - $373K/yr
The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical ...
Clinical Review Medical Director - Neurology - Remote
Boston, MA · Remote
$248K - $373K/yr
The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical ...
Clinical Review Medical Director - Neurology - Remote
Boston, MA · On-site +1
$248K - $373K/yr
The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical ...
Clinical Review Medical Director - Neurology - Remote
Boston, MA · On-site +1
$248K - $373K/yr
The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical ...
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Nurse Reviewer I
$33.92 - $44.42/hr
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
Initial Clinical Reviewer information
See salary details
$24.28 - $26.29
6% of jobs
$26.29 - $28.30
7% of jobs
$28.30 - $30.31
5% of jobs
$31.47 is the 25th percentile. Wages below this are outliers.
$30.31 - $32.32
11% of jobs
$32.32 - $34.33
11% of jobs
The median wage is $35.04 / hr.
$34.33 - $36.34
28% of jobs
$36.34 - $38.35
3% of jobs
$39.44 is the 75th percentile. Wages above this are outliers.
$38.35 - $40.36
6% of jobs
$40.36 - $42.37
13% of jobs
$42.37 - $44.38
6% of jobs
$44.38 - $46.39
3% of jobs
$24
$35
$46
How much do initial clinical reviewer jobs pay per hour?
As of Jul 25, 2026, the average hourly pay for initial 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 are some challenges Initial Clinical Reviewers commonly face when assessing medical claims, and how can they effectively manage these challenges?
Initial Clinical Reviewers often encounter challenges such as interpreting incomplete documentation, staying current with evolving clinical guidelines, and balancing efficiency with accuracy under tight deadlines. To manage these challenges, reviewers typically rely on strong critical thinking skills, ongoing training, and collaboration with colleagues or senior clinicians for complex cases. Effective time management and clear communication with providers or other team members also help ensure thorough and timely reviews.
What is the difference between Initial Clinical Reviewer vs Claims Reviewer?
| Aspect | Initial Clinical Reviewer | Claims Reviewer |
|---|---|---|
| Required Credentials | Healthcare license, clinical experience, certifications (e.g., RN, LPN) | Insurance knowledge, certification in claims processing (e.g., CPC) |
| Work Environment | Hospitals, clinics, healthcare organizations | Insurance companies, third-party administrators |
| Employer & Industry Usage | Healthcare providers, managed care | Insurance carriers, claims processing firms |
| Common Search & Comparison Intent | Understanding clinical review roles in healthcare | Understanding claims processing and review roles |
The main difference is that Initial Clinical Reviewers focus on evaluating patient care and medical necessity based on clinical standards, while Claims Reviewers primarily assess insurance claims for accuracy and compliance. Both roles require industry-specific certifications and work within healthcare or insurance environments, but their core responsibilities differ significantly.
What are the key skills and qualifications needed to thrive as an Initial Clinical Reviewer, and why are they important?
To thrive as an Initial Clinical Reviewer, you need in-depth clinical knowledge, attention to detail, and a degree in nursing or a related healthcare field, often accompanied by an active RN or similar licensure. Familiarity with utilization management software, electronic health records (EHR), and knowledge of regulatory standards such as CMS and NCQA are typically required. Strong analytical skills, critical thinking, and effective communication help professionals excel in this role. These competencies are crucial to accurately assess medical necessity, ensure compliance, and facilitate quality healthcare decisions.
What is an Initial Clinical Reviewer?
An Initial Clinical Reviewer is a healthcare professional who evaluates medical records, treatment requests, and clinical documentation to determine if services are medically necessary and meet established guidelines. They often work for insurance companies, healthcare organizations, or third-party administrators, reviewing cases before approval or further review. Their assessments help ensure that patients receive appropriate care while controlling healthcare costs and maintaining compliance with regulations.
More about Initial Clinical Reviewer jobs
What states have the most Initial Clinical Reviewer jobs? States with the most job openings for Initial Clinical Reviewer jobs include:
What job categories do people searching Initial Clinical Reviewer jobs look for? The top searched job categories for Initial Clinical Reviewer jobs are:
Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Posted 10 days ago
Elevance Health rating
7.7
Based on 348 frontline employees who took The Breakroom Quiz
184th of 281 rated insurance
Job description
Anticipated End Date:
2026-07-21Position Title:
Case Reviewer - NP/PAJob Description:
Case Reviewer - NP/PA
Location: Miami, FL
Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.
TheCase Reviewer - NP/PA will be responsible for conducting pre-authorization, out of network and appropriateness of tests by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of required tests, medications, interventional procedures and surgeries to ensure quality member outcomes, and to optimize member benefits.
How you will make an impact:
- Receives pre-authorization requests from front-line intake and nurse reviewers.
- Conducts initial medical necessity clinical screenings.
- Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director.
- Works closely with Medical Directors to review and make recommendations regarding medical necessity of requested tests, medications, interventional procedures and surgeries.
- Documents the results of the initial clinical review and determination in the pre-certification system.
- Conducts initial medical necessity review of out of network pre-authorization requests for services.
- Conducts review of grievance and appeals requests to provide to Medical Directors.
Minimum Requirements:
- Requires MA/MS from an ARC-PA (Accreditation Review Commission for the Physician Assistant) accredited program or an ACEN/CCNE (Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education) accredited program.
- Minimum of 3 years of clinical experience is also required; or any combination of education and experience which would provide an equivalent background.
- Certified and current, active, unrestricted license as a Physician Assistant or APRN (Advanced Practice Registered Nurse) in applicable state(s) required.
- AAPA (American Academy of PAs) and applicable state license required for Physician Assistants. APRN and applicable state license(s) required for Nurse Practitioners.
Preferred Skills, Capabilities and Experiences:
- Utilization Management experience, including complex UM reviews.
- Experience with appeals, disputes and audits.
Job Level:
Non-Management Non-ExemptWorkshift:
1st Shift (United States of America)Job Family:
MED > Licensed/Certified - OtherPlease be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.
What Elevance Health employees say
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About Elevance Health
Sourced by ZipRecruiter
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
Industry
Health care and social assistance
Company size
10,000+ Employees
Headquarters location
Indianapolis, IN, US
Year founded
2004