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Nurse Reviewer Jobs (NOW HIRING)

Zelis

Clinical Nurse Reviewer

Saint Petersburg, FL · On-site

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Zelis

Clinical Nurse Reviewer

Boston, MA

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Zelis

Clinical Nurse Reviewer

Atlanta, GA

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Zelis

Clinical Nurse Reviewer

Saint Louis, MO · On-site

Position Overview The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria ...

Zimmerman Associates, Inc.

$24.13/hr

Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty referrals for Active-Duty Service Members and TRICARE Prime beneficiaries enrolled at Military ...

Zimmerman Associates, Inc.

$23.56/hr

Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty referrals for Active-Duty Service Members and TRICARE Prime beneficiaries enrolled at Military ...

Cohere Health

Lead RN Reviewer

$35 - $37/hr

Lead RN Reviewer Cohere's Service Operations team is responsible for ensuring that our healthcare partners are supported throughout their lifecycle of using the platform. The Lead RN Reviewer in ...

Astiva Health

UM Nurse Reviewer

Orange, CA

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

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How much do nurse reviewer jobs pay per hour?

As of Aug 16, 2026, the average hourly pay for nurse reviewer in the United States is $37.04, according to ZipRecruiter salary data. Most workers in this role earn between $34.13 and $41.35 per hour, depending on experience, location, and employer.

What is a nurse reviewer?

A Nurse Reviewer is a registered nurse who evaluates medical records, claims, and treatment plans to ensure that healthcare services are medically necessary, appropriate, and compliant with policies or regulations. They often work for insurance companies, government agencies, or healthcare organizations, reviewing clinical documentation and making recommendations about coverage or care. Nurse Reviewers play a vital role in utilization management, quality assurance, and preventing healthcare fraud. Their assessments help manage costs while ensuring patients receive proper care.

What are some typical challenges nurse reviewers face when coordinating with healthcare providers and insurance companies?

Nurse Reviewers often encounter challenges such as balancing the need to advocate for patient care with adhering to insurance guidelines and policies. They must communicate complex medical information clearly to both healthcare providers and insurance representatives, sometimes dealing with time-sensitive cases or incomplete documentation. Effectively managing these interactions requires strong organizational skills, attention to detail, and the ability to navigate differing priorities while maintaining professionalism and empathy.

What is the difference between Nurse Reviewer vs Nurse Auditor?

AspectNurse ReviewerNurse Auditor
CredentialsRegistered Nurse (RN) license, often with clinical experienceRegistered Nurse (RN) license, with additional auditing or compliance training
Work EnvironmentHealthcare facilities, insurance companies, or third-party review organizationsInsurance companies, healthcare organizations, or consulting firms
Primary ResponsibilitiesReview patient records for medical necessity and quality of careAudit claims and documentation for billing accuracy and compliance

While both Nurse Reviewers and Nurse Auditors have clinical backgrounds and work in healthcare settings, Nurse Reviewers primarily evaluate patient records for quality and necessity, whereas Nurse Auditors focus on financial and billing compliance. The roles often overlap but serve different aspects of healthcare quality and financial integrity.

What are the key skills and qualifications needed to thrive as a nurse reviewer?

To thrive as a Nurse Reviewer, you need a strong clinical background, analytical skills, and an active RN license, often complemented by experience in utilization review or case management. Familiarity with medical coding systems (such as ICD-10 and CPT), electronic health records (EHRs), and utilization management software is typically required. Excellent written communication, critical thinking, and attention to detail are vital soft skills that contribute to effective documentation and fair assessment of cases. These abilities ensure accurate and efficient review of medical records, compliance with policies, and optimal patient outcomes.

How to become a nurse reviewer?

To become a nurse reviewer, you typically need a valid registered nurse (RN) license and several years of clinical nursing experience. Strong attention to detail, excellent communication skills, and familiarity with medical documentation are essential, and some roles may require knowledge of medical coding or health information systems.
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Nurse Reviewer jobs near you
Infographic showing various Nurse Reviewer job openings in the United States as of August 2026, with employment types broken down into 86% Full Time, and 14% Part Time. Highlights an 71% In-person, and 29% Remote job distribution, with an average salary of $77,034 per year, or $37 per hour.

Clinical Nurse Reviewer

Zelis

Saint Petersburg, FL • On-site

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 29 days ago

Zelis rating

7.6

Company rating: 7.6 out of 10

Based on 11 frontline employees who took The Breakroom Quiz

154th of 244 rated software companies

Job description

At Zelis, we Get Stuff Done. So, let's get to it!
A Little About Us
Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.
At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.
A Little About You
You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.
Position Overview
The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records and coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest possible savings for clients.
What You'll Do:

  • Conduct routine reviews of medical records and supporting documentation for compliance with clinical guidelines and organizational standards.
  • Validate accuracy and completeness of documentation for basic cases, ensuring essential data elements are present.
  • Identify and flag missing or incomplete information; escalate unresolved issues to senior reviewers.
  • Contact medical providers via phone or email and request a review of billing inconsistencies.
  • Communicate findings clearly to internal teams, providing concise feedback on documentation gaps.
  • Maintain current knowledge of healthcare regulations, payer requirements, and organizational policies.
  • Support administrative tasks such as data entry, case tracking, and report preparation.
  • Participate in training sessions and shadow senior reviewers to develop clinical review skills.
  • Maintain personal production metrics and quality assurance scores consistently.
  • Maintain awareness of and ensure adherence to Zelis standards regarding privacy.
  • Attends company training and regularly attends local meetings (once per month).
What You'll Bring to Zelis:
  • Current/active RN License.
  • Typically has a BA or 3-5 years of experience.
  • Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents.
  • Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs preferred.
  • Familiarity with EHR systems and Microsoft Office.
  • Exceptional attention to detail and ability to follow established processes.
  • Committed to continuous learning and professional development, with a passion for improving healthcare quality and outcomes.
  • Proactive and self-motivated, with a strong sense of ownership and accountability.
  • Ability to withstand long period of computer work while utilizing multiple computer screens at one time.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.
Location and Workplace Flexibility
Zelis is headquartered in the U.S., with multiple locations across the country and in Hyderabad, India. Check out our locations to learn more about our offices. All employee work locations are based on the needs of the position and are determined by the Leadership team. In-office work and activities vary based on work and team objectives in accordance with Company policies.
While location expectations vary by role, candidates within approximately 50 miles of a U.S. office are generally preferred to support collaboration when needed. Our hybrid approach is flexible, and in-office presence is guided by team and business needs rather than a fixed weekly schedule.
Base Salary Range
$59,000.00 - $75,050.00
At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.
Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.
Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

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