ZipRecruiter

Log In

1

Initial Clinical Reviewer Jobs (NOW HIRING)

Acentra Health, LLC

Clinical Reviewer (SCA-Remote)

Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process ...

Acentra Health, LLC

Clinical Reviewer (SCA-Remote)

Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process ...

next page

Showing results 1-20

All JobsInitial Clinical Reviewer Jobs

Initial Clinical Reviewer information

See salary details

$24

$35

$46

How much do initial clinical reviewer jobs pay per hour?

As of Jun 10, 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?

AspectInitial Clinical ReviewerClaims Reviewer
Required CredentialsHealthcare license, clinical experience, certifications (e.g., RN, LPN)Insurance knowledge, certification in claims processing (e.g., CPC)
Work EnvironmentHospitals, clinics, healthcare organizationsInsurance companies, third-party administrators
Employer & Industry UsageHealthcare providers, managed careInsurance carriers, claims processing firms
Common Search & Comparison IntentUnderstanding clinical review roles in healthcareUnderstanding 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:
Initial Clinical Reviewer jobs near you
Infographic showing various Initial Clinical Reviewer job openings in the United States as of June 2026, with employment types broken down into 6% Locum Tenens, 24% As Needed, 6% Full Time, and 64% Contract. Highlights an 92% Physical, 2% Hybrid, and 6% Remote job distribution, with an average salary of $74,707 per year, or $35.9 per hour.
Physician Clinical Reviewer - Dermatology- REMOTE

Physician Clinical Reviewer - Dermatology- REMOTE

Prime Therapeutics LLC

Albuquerque, NM • On-site, Remote

$90.87 - $154.33/hr

Part-time

Posted 29 days ago

Prime Therapeutics rating

7.7

Company rating: 7.7 out of 10

Based on 44 frontline employees who took The Breakroom Quiz

18th of 99 rated pharmacies

Job description

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.
Job Posting Title
Physician Clinical Reviewer - Dermatology- REMOTEJob Description
Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan members and staff whenever a physician`s input is needed or required.
Physician Clinical Reviewer- Job Description Responsibilities
  • Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer.
  • Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax.
  • Provides clinical rationale for standard and expedited appeals.
  • Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
  • Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines.
  • Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner.
  • Participates in on-going inter-rater reliability training and testing
  • Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support.
  • On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
  • On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director
  • Other duties as assigned.

Education & Experience
  • Education Level
    • DO
    • MBBS
    • MD
  • Required
    • Yes
    • Yes
    • Yes
  • Fields of Study
  • Experience Level
    • 5+ years
  • Required
    • Yes
  • Details
    • Clinical

Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Additional Qualifications
Preferred Qualifications
Physical Demands
  • Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse"
  • Must be able to constantly operate a computer and/or other office productivity equipment
  • Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information
  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Potential pay for this position ranges from $90.87 - $154.33 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.

What Prime Therapeutics employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Prime Therapeutics logo

About Prime Therapeutics

Sourced by ZipRecruiter

Prime Therapeutics, located in Eagan, MN, is a pharmacy benefits management company that has been serving the healthcare industry since its foundation. They are an integral participant in the medical sector, specifically in the realm of health insurance. They focus on providing innovative pharmacy benefits and services to more than 30 million members nationwide. Besides their main pharmacy benefit management, they offer mail service pharmacy, specialty pharmacy, benefits management, and consultative engagement services to ensure individuals have continuous access to affordable prescription drugs. Prime Therapeutics, founded around three decades ago, has grown to stand out as a leader in its industry, thanks to its commitment to improving the health of its clients.

Industry

Insurance services

Company size

1,001 - 5,000 Employees

Headquarters location

Eagan, MN, US

Year founded

1987

Social media

FacebookTwitter

View All Prime Therapeutics Jobs

Apply