Medical Reviewer

• Perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Document decisions using indicated protocol sets or clinical guidelines.
• Provide support and review of medical claims and utilization practices.
• Monitor process's timeliness in accordance with contractor standards.
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilize allocated resources to back up review determination.
• Review interdepartmental requests and medical information in a timely/effective manner to complete utilization process.
• Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Perform screenings/assessments and determine risk via telephone.
• Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provide education to members and their families/caregivers.
• Review first level appeal and ensure utilization or claim review provides thorough documentation of each determination and basis for each.
• Conduct research necessary to make thorough/accurate basis for each determination made.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participate in quality control activities in support of the corporate and team-based objectives.

Medical Reviewer I

• The Metabolic and Bariatric Surgery Clinical Reviewer (MBSCR) key responsibility is to collect and submit accurate, complete, and timely data to the MBSAQIP Registry.
• Identify process improvement opportunities in the data collection process.
• Collaborate with metabolic & bariatric and general surgery departments to identify opportunities for clinical quality improvement.
• Participate in bariatric program meetings and teleconferences (MBS Committee Meetings are required).
• Actively participate in data compiling for audits and (re)accreditation or site visits and assist coordinator as needed.
• Manage Accreditation criteria to ensure bariatric program meets expectations set forth by MBSAQIP.
• Work closely with the MBS (Metabolic and Bariatric Surgery) Coordinator.
• Manage workflows to meet established deadlines and perform abstraction and data entry for successful data submission to MBSAQIP Registry.
• Consistently complete targeted clinical case reviews utilizing clinical decision making, critical thinking, and objectivity.
• Collect preoperative, intraoperative, 30-day postoperative, and long-term follow-up data components for the program.
• Identify streamlining and process improvement opportunities in the data collection process.

Registered Nurse, Bariatric Clinical Reviewer

• Performs medical claim reviews for one or more of the following: 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
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement
• Monitors process’s timeliness in accordance with contractor standards
• Documents medical rationale to justify payment or denial of services and/or supplies
• Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines
• Participates in quality control activities in support of the corporate and team-based objectives
• Provides 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

Medical Reviewer II – Prior-Auth A/B MAC

• Provide clinical review support on a full-time basis to assist with an increase in inventory and client demand
• Review medical records for medical necessity, level of care, authorization compliance, and payer guideline alignment across inpatient and outpatient services
• Support timely appeal submissions and inventory management while maintaining quality and compliance standards

Clinical Review Specialist

• Review ABA treatment plans and supporting clinical documentation for medical necessity and clinical appropriateness and compare platform-generated outputs, analyses, and recommendations against independent clinical review findings.
• Identify discrepancies, edge cases, or workflow gaps and provide structured feedback to support ongoing platform refinement
• Collaborate cross-functionally with clinical, product, engineering, and account management teams to help improve the product to ensure stellar customer experience
• Participate in calibration and inter-rater reliability activities to ensure consistency
• Assist in development and refinement of quality assurance and improvement methodologies, audit tools, and outcome metrics
• Perform other data validation tasks as needed
• Maintain accurate and timely documentation of findings and recommendations

Clinical Quality Reviewer – BCBA

• Evaluate medical records and prepare concise clinical summaries
• Provide independent medical opinions in response to specific questions posed by clients
• Conduct thorough medical record reviews on orthopedic spine conditions, injuries, and treatments
• Participate in peer-to-peer discussions when necessary
• Answer client-specific questions regarding orthopedic spine diagnoses, treatment plans, and surgical interventions
• Apply current clinical guidelines and standards of care to all reviews

Orthopedic Spine Surgeon – Medical Reviewer

• 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.

• Lead senior-level clinical review of complex dermatology cases
• Provide structured clinical reasoning and guideline-aligned commentary
• Resolve clinical disagreements across reviewer groups
• Contribute to development of evaluation frameworks and methodologies
• Support AI model evaluation through expert advisory sessions
• Provide subspecialty input on complex or ambiguous cases
• Ensure high-quality, clinically defensible documentation
• Collaborate with peer reviewers and research stakeholders
• Maintain adherence to clinical and project protocols

Senior Clinical Reviewer – Dermatology AI

• Ensure data readiness for important milestones including, but not limited to, interim analysis, final analysis, snapshots to support submissions, Data Monitoring Committee reviews and publications
• Review participant level data across a study in adherence with CRF Completion guidelines (CCGs) and the Data Review Plan (DRP)
• Conduct point-to-point data checks (e.g. verifying the presence of a lab test that satisfies study inclusion criteria) and interpretive analysis (e.g. reviewing to identify inconsistencies in the participant’s data).
• Generate queries on discrepant data and follow to resolution including escalation of issues that cannot be resolved through the query process
• Create and use data review best practices and associated data review tools to identify trends and any safety signals
• May identify protocol deviations during routine clinical review and escalation as appropriate
• Follow relevant SOPs and regulations, have an excellent understanding of and comply with applicable training requirements, constantly seeking further improvements in quality and efficiency of clinical procedures
• May liaise with data management, clinical and site management along with other members of the study team Attend Clinical Meetings and Study Meetings, as necessary

Clinical Data Reviewer, Internal Medicine

• Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff.
• Clinical reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process.
• Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
• Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale, while providing optimum customer service through professional/accurate communication and maintaining NCQA and health plans required timeframes.
• Documents all communication with medical office staff and/or treating provider.
• Practices and maintains the principles of utilization management by adhering to policies and procedures.
• Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations, as well as, being audited to ensure guidelines are applied appropriately.

Clinical Reviewer, Nurse – Radiology

• Identify errors in data through data review
• Perform ongoing review of clinical participant data
• Issue and follow up on clinical data queries
• Monitor site data entry performance
• Collaborate with clinical teams for data review

Clinical Data Reviewer

• Conduct utilization reviews up to and including the appeal level. This includes chart screen, completing electronic worksheets, entering the required information, and making level one denial decisions when necessary.
• Conduct quality and clinical study data collection reviews. This includes a chart review, complete detailed electronic data worksheets.
• Act as a resource for the administrative staff in training, problem-solving, and clarifying procedures. Will provide technical assistance and conduct/participate in staff huddles.
• Participate in collaborative training specific to clinical study objectives.
• Other activities as may be deemed necessary.

Registered Nurse Clinical Reviewer

• Responsible for support and assistance for all Oncology administrative and clinical utilization management and quality improvement functions under the auspices of the office of the Chief Medical Officer.
• Conducts initial clinical review of incoming cases, rendering authorization approval based on established clinical criteria or escalating to a Field Medical Director if authorization cannot be approved during initial review.
• Responsible for acting as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
• Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.
• Responsible for maintaining and operating the Guideline Directed Treatment plans including communicating with offices regarding treatment recommendation.
• Responsible for communicating need for additional clinical information to ordering providers.
• Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the Oncologists.
• Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.
• Responsible for completion of UM projects and participation in site visit reviews.
• Respect and maintain HIPAA confidentiality guidelines.
• Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening.
• Acts as an interdepartmental liaison between all offices, departments, and committees.
• Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.
• Will work with the Director of Clinical Operations to ensure client satisfaction.
• Perform all peer clinical review activities while located in a state or territory of the United States.
• Acts with honor and integrity, serving as a role model for the company.
• Performs other duties as assigned.

Clinical Reviewer, Nurse Practitioner/Physician Assistant – Oncology

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Assessing medical necessity, appropriateness, and reimbursement eligibility while documenting decisions
• Reviewing medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Educating internal and external teams on medical review processes, coverage determinations, and coding requirements
• Supporting quality control activities to meet corporate and team objectives
• Providing guidance to LPN team members and supporting non-clinical staff through training and discussions
• Assisting with special projects and additional responsibilities as assigned

Home Health RN – Medical Claims Reviewer

• Conduct claim reviews against medical records to determine claim accuracy for claims payment
• Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation
• Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities
• Assist the audit and investigative teams in the development of clinical and coding based audit tools
• Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies
• Collaborate with other departments including Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management and Legal
• Responsible for maintaining confidentiality of all sensitive investigative information
• Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)

Program Integrity Clinical Reviewer II, Readmission Experience Preferred

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines
• Documents decisions using indicated protocol sets or clinical guidelines
• Provides support and review of medical claims and utilization practices
• Participate in quality control activities in support of the corporate and team-based objectives
• Perform medical claim reviews for one or more of the following: 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
• Document medical rationale to justify payment or denial of services and/or supplies

Medical Reviewer III

• Perform medical claim reviews for one or more of the following: 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 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

• Ensure data readiness for important milestones
• Review participant level data across a study in adherence with CRF Completion guidelines and the Data Review Plan
• Conduct point-to-point data checks and interpretive analysis
• Generate queries on discrepant data and follow to resolution
• Create and use data review best practices and associated data review tools
• May identify protocol deviations during routine clinical review and escalation as appropriate
• Follow relevant SOPs and regulations
• Liaise with data management, clinical and site management along with other members of the study team
• Attend Clinical Meetings and Study Meetings, as necessary

See all jobs on JobTailor

Medical Reviewer I

Registered Nurse, Bariatric Clinical Reviewer

Medical Reviewer II – Prior-Auth A/B MAC

Medical Reviewer II – Prior-Auth A/B MAC

Clinical Review Specialist

Clinical Quality Reviewer – BCBA

Orthopedic Spine Surgeon – Medical Reviewer

RN Medical Reviewer III

RN Medical Reviewer III

Senior Clinical Reviewer – Dermatology AI

Clinical Data Reviewer, Internal Medicine

Clinical Reviewer, Nurse – Radiology

Clinical Data Reviewer

Registered Nurse Clinical Reviewer

Clinical Reviewer, Nurse Practitioner/Physician Assistant – Oncology

Home Health RN – Medical Claims Reviewer

Program Integrity Clinical Reviewer II, Readmission Experience Preferred

Medical Reviewer III

Medical Reviewer III

Clinical Data Reviewer – Internal Medicine