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Initial Clinical Reviewer Jobs (NOW HIRING)

Acentra Health, LLC

Clinical Reviewer (SCA-Remote)

  • Medical

  • Life

  • Retirement

  • PTO

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

Clinical Reviewer-RN

Mclean, VA · On-site

  • Medical

  • Retirement

  • PTO

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 ...

Gaudenzia

Clinical Review Clinician

Washington, DC · On-site

$85K/yr

Supervise initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines * Review and approve initial evaluations and clinical documentation against clinical ...

Gaudenzia

Clinical Review Clinician

Washington, DC · On-site

$85K/yr

Supervise initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines * Review and approve initial evaluations and clinical documentation against clinical ...

Elevance Health

Nurse Reviewer 1

Tampa, FL · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

Elevance Health

Nurse Reviewer 1

Wilmington, DE · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

Elevance Health

Nurse Reviewer 1

Mason, OH · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

Elevance Health

Nurse Reviewer 1

Miami, FL · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

Elevance Health

Nurse Reviewer 1

Atlanta, GA · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

Elevance Health

Nurse Reviewer 1

Tampa, FL · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

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Initial Clinical Reviewer information

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How much do initial clinical reviewer jobs pay per hour?

As of Aug 20, 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 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.

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 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.

How to be an Initial Clinical Reviewer?

To become an Initial Clinical Reviewer, candidates typically need a healthcare-related degree such as nursing, pharmacy, or a related field, along with experience in clinical assessment or case review. Certification in case management or relevant licenses can enhance prospects, and strong analytical, communication, and documentation skills are essential for performing reviews accurately and efficiently.
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 August 2026, with employment types broken down into 4% As Needed, 70% Full Time, 17% Part Time, and 9% Contract. Highlights an 94% Physical, 1% Hybrid, and 5% Remote job distribution, with an average salary of $74,707 per year, or $35.9 per hour.

REMOTE Physician Clinical Reviewer-Radiology

Evolent

Arlington, VA • On-site

Other

Re-posted 17 days ago

Evolent rating

8.4

Company rating: 8.4 out of 10

Based on 18 frontline employees who took The Breakroom Quiz

69th of 494 rated business services

Job description

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.



Collaboration Opportunities:  


  • Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required.



What You Will Be Doing:


  • Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

  • Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.

  • Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.

  • Aids and acts as a resource to Initial Clinical Reviewers.

  • Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.

  • May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.

  • Participates in on-going training per inter-rater reliability process.



Qualifications:


  • MD/DO/MBBS

  • Minimum of five (5) years’ experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is preferred

  • Current, unrestricted clinical license in home state medicine or required specialty-

  • Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs

  • Active Board Certification by an accredited organization

  • Strong clinical, management, communication, and organizational skills

  • Energetic and curious with a passion for quality and value in health care

  • Computer Proficiency

  • Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.

  • No history of a major disciplinary or legal action by a state medical board

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