Medical Reviewer

• Perform medical claim reviews for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Monitors process’s timeliness in accordance with contractor standards
• Document medical rationale to justify payment or denial of services and/or supplies
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc.
• Participate in quality control activities in support of the corporate and team-based objectives
• Provide guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assists with special projects and specialty duties/responsibilities as assigned by management

Reviewer II, Medical

• Perform medical claim reviews for claims requiring preauthorization or appeals
• Determine medical necessity and appropriateness for coverage and reimbursement
• Document medical rationale for payment or denial of services
• Educate staff on medical reviews, coverage determinations, and coding procedures
• Participate in quality control activities

• Lead clinical and scientific data review activities across assigned clinical studies, ensuring data accuracy, consistency, and alignment with protocol expectations and therapeutic objectives.
• Identify insights, trends, and risks through comprehensive data analysis and interpretation, enabling early detection of data quality issues and safety signals.
• Design, test, and refine clinical data review tools—including listings, reports, and visualizations—to support robust data exploration, signal detection, and discrepancy management.
• Collaborate closely with cross‑functional teams, including Clinical Development, Biostatistics, Pharmacovigilance, and Study Operations, to drive data‑driven decision‑making and ensure high-quality trial execution.
• Manage timelines and deliverables with a strong commitment to quality, efficiency, and proactive communication.
• Contribute to risk management by identifying, documenting, and supporting mitigation of study‑level data risks.
• Support strategic initiatives within and beyond the Data Management organization, bringing scientific and operational insight to process innovation and continuous improvement.
• Leverage metrics and analytics to monitor data trends, assess study health, and enhance data review strategies.

Principal Clinical Data Reviewer – Scientist

• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.

RN Medical Reviewer III

• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitor process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assist with special projects and specialty duties/responsibilities as assigned by management.

Medical Reviewer jobs in North Carolina

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Reviewer II, Medical

Reviewer II, Medical

Principal Clinical Data Reviewer – Scientist

RN Medical Reviewer III

RN Medical Reviewer III