Clinical Reviewer Job Description

A Clinical Reviewer judges whether care is medically necessary. In payer-side utilization review, the work centers on Medicare and Medicaid claims and prior authorization requests, where each determination must hold up against national and local coverage policies, accepted coding practice, and contractual turnaround deadlines. Reviewers approve cases that clearly meet criteria such as NCQA/URAC-aligned standards and route the rest to a physician consultant or Medical Director for a final decision. Speed matters under those deadlines, but a defensible, well-documented determination matters more.

As the Clinical Reviewer, you protect patients and payers by ensuring every approved service or device is clinically supported and every denial is documented clearly enough to withstand appeal and regulatory audit. You work within a utilization management team under clinical leadership, handling referral and claim caseloads and serving as a clinical resource to care coordinators.

Career Impact: Rendering Medicare and Medicaid medical necessity decisions gives LPNs, RNs, and licensed clinicians a payer-side specialty that extends their practice beyond bedside care.

Business Impact: Accurate determinations within contractual turnaround standards keep prior authorization backlogs from delaying patient care and prevent payment for unsupported services.

Growth Opportunity: Coding credentials such as CPC or CIC, often earned on the job within two years, open paths toward probe review lead and QA trainer roles.

• Review patient records and clinical documentation against medical necessity criteria to determine appropriateness of requested services and devices.
• Determine approval or referral to the physician consultant or Medical Director, documenting denial reasons in sufficient detail for correspondence.
• Request additional clinical information from providers when records are insufficient to render a determination.
• Monitor case progress to complete reviews within contractual and regulatory turnaround time standards.
• Abstract review data accurately on the designated review tool and submit administrative documentation to appropriate parties.
• Apply Medicare, Medicaid, and contract-specific guidelines, maintaining current knowledge of coverage policies and billing and coding practices.
• Educate providers, suppliers, and peers on review findings and applicable guidelines to reduce repeat documentation errors.
• Safeguard medical record confidentiality through secured files and adherence to HIPAA policies.

• Nursing diploma, associate's degree, or clinical master's degree for behavioral health review, or equivalent work experience.
• 1 or more years of utilization review or prior authorization experience, with 2 years of clinical practice.
• Current, unrestricted clinical license (RN, LPN/LVN, LCSW, or LCPC) in the state of practice.
• Working knowledge of Medicare, Medicaid, or managed care regulations governing coverage, contract terms, and medical necessity.
• Strong clinical assessment and critical thinking skills to apply criteria to complex cases independently.
• Medical record abstraction skills, including understanding of record organization, medical terminology, and disease processes.
• Excellent verbal and written communication skills for provider correspondence and physician consultant referrals.
• Demonstrated organizational and prioritization skills to manage multiple concurrent cases against contractual turnaround deadlines.

• Coding certification such as CPC, CIC, or COC, or working knowledge of CPT/HCPCS and ICD code sets.
• Familiarity with evidence-based medical necessity criteria sets and current NCQA/URAC accreditation standards.
• Background in home health, Durable Medical Equipment, or acute care review, including governmental home health regulations.
• Prior experience leading review projects, conducting QA reviews, or developing training materials for provider and peer education.

• Turnaround time compliance rate percentage of cases closed within contractual deadlines.
• Determination accuracy rate on QA audits, reflecting correct application of medical necessity criteria.
• Overturn rate on appeal, showing how well documented denials hold up.
• Cases reviewed per day against production standards, measuring sustained caseload throughput.
• Physician referral appropriateness rate, percentage of escalations the consultant deems warranted.
• Pended case rate for missing information, tracking how quickly records requests resolve.

• Base Salary Range: $62,000 to $88,000 annually, higher for RN and licensed master's clinicians
• Bonus: Annual performance bonus of 3% to 7% tied to production and accuracy
• Equity: Typically none, though some publicly traded payers offer employee stock purchase plans
• Health Benefits: Medical, dental, and vision coverage with subsidized premiums and HSA or FSA options
• PTO: 15 to 22 days annually plus 8 to 10 paid holidays
• Common Perks: Remote or hybrid work, CEU reimbursement, license renewal support, and coding certification funding

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Offers of employment are contingent on a successful background check and license verification. Drug screening is also required where the plan or client contract calls for it. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic protected by federal, state, or local law. Reasonable accommodations are available on request throughout the hiring process. Candidates must be authorized to work in the United States.

The Clinical Reviewer delivers clinical payment determinations on Medicare and Medicaid claims and prior authorization requests, reviewing medical records to confirm billed services are reasonable, necessary, and properly coded. Reporting to review leadership within a claims review team, the reviewer collaborates with peers and Subject Matter Experts to educate providers and suppliers, supporting accurate payments and compliance with national and local policies.

Key Responsibilities

• Meet performance standards, quality measures, and production standards.
• Review, research, and analyze medical records and make independent payment determinations based on Medicare/Medicaid regulations.
• Provide recommendations for action based on reviews.
• Identify, create, and provide education/training to providers/suppliers/peers on review findings and Medicare/Medicaid guidelines.
• Collaborate with peers and leadership, and attend and actively participate in meetings.
• Evaluate, enhance, and develop processes and communicate necessary enhancements.
• Serve as a resource for the team.
• Perform quality/accuracy reviews and develop and conduct effective staff training as needed.
• Serve as project, specialty, and/or probe review lead by managing workload, assigning reviewers, monitoring claims, volume of work, and reports, and taking action on timeliness concerns.
• Identify training needs, create or develop effective training materials, and work with Subject Matter Experts (SMEs).
• Analyze QA reviews, create and complete individual re-training plans as needed, and identify updates for review guides.
• Research review topics to understand project and/or specialty scope and requirements, and articulate them to the team as appropriate.
• Answer questions, resolve problems, provide constructive feedback to staff, and provide team/staff leadership, motivation, and support.
• Represent the team, facilitate various internal and external meetings, and complete reporting and analysis for various internal and external reports.

Required Qualifications

• Willingness to obtain a Bachelor of Science in Nursing (BSN) within 2 years.
• Current RN license or other professional medical license as outlined in the Statement of Work (SOW) in the state of employment.
• CPC, CIC, COC (or other) coding certification or willingness to obtain within 2 years (dependent upon department needs).
• 2 years' clinical experience, plus an additional 3 years of clinical experience.
• Demonstrated proficiency as a Clinical Reviewer or equivalent position.
• Prior leadership, project management, quality assessment/control, and management experience.
• Prior experience developing and providing effective training.
• Knowledge of Medicare or Medicaid regulations and CPT/HCPCS and ICD codes, with ongoing maintenance of clinical and Medicare/Medicaid related knowledge.
• Demonstrated leadership and project management skills.
• Strong computer skills including Microsoft Office proficiency.
• Excellent communication skills and demonstrated prioritization, problem-solving, and organizational skills.
• Demonstrated efficiency/innovative thinking and ability to operate autonomously.

Embedded within the hospital's Department of Surgery, the Surgical Clinical Reviewer owns the collection and entry of preoperative, operative and postoperative data into the ACS NSQIP registry while leading the ISCR enhanced recovery program. Working closely with surgeons, nursing, medical records staff, and the ISCR core team, the reviewer shares performance data that reveals clinical quality improvement opportunities and strengthens surgical outcomes for patients.

Core Functions

• Train on the ACS registry and collect baseline and post-intervention data for the ISCR program.
• Lead the ISCR initiative with the ISCR core team and direct communication between multiple disciplines to ensure success of the ISCR program.
• Collect preoperative, operative and postoperative data components in a timely manner through effective utilization of the hospital medical record systems.
• Identify streamlining and process improvement opportunities in the data collection process.
• Demonstrate appropriate utilization of resources to obtain valid, reliable data and utilize software applications for data collection and analysis.
• Ensure accurate and timely entry of data into the program's database.
• Organize regular ISCR meetings, set the agenda, take minutes, and encourage and empower staff to actively participate.
• Manage documentation and progress towards goals.
• Share performance data with the ISCR team and frontline staff on a regular basis.
• Work with other ISCR core team members to gain IRB approval.
• Work effectively with patients, families, and staff, and establish effective working relationships with members of the hospital community, especially staff in the Surgery, Medicine, Nursing, Medical Records and Information Systems Departments.
• Contact patients and/or families via telephone and/or written communications postoperatively to identify possible occurrences associated with surgical procedures performed at the hospital.
• Serve as an educational resource on the ACS for internal and external audiences by developing educational material and delivering presentations.

Qualifications & Experience

• Graduate of an accredited school of nursing, with a Bachelor of Science in Nursing degree preferred.
• Current state license as a Registered Nurse, with RHIA or RHIT preferred but not required.
• Ability to complete training on the ACS registry and necessary data collection.
• Applicable clinical experience, with a preferred minimum of one year of experience in a hospital surgery department, surgery clinic, clinical research or medical records.
• Required clinical chart review and abstraction experience.
• Experience gathering information in a complex hospital system environment through sources such as medical records, surgery clinics, Social Security death index, direct patient contact, accounts payable, and legal counsel.
• Database data entry and/or management experience preferred.
• Clinical knowledge and understanding of patient care, with quality improvement or patient safety knowledge and experience preferred.
• Basic statistical skills and knowledge.
• Familiarity and comfort with MS Office products (Word and Excel required, PowerPoint and Access preferred) and the ability to learn new software and web applications for data entry and report generation.
• Ability to build relationships, gain alignment for clinical support, and articulate questions to receive an appropriate level of support from superiors and peers.
• Ability to interact with all members of the surgical team and administrative staff in a professional and courteous manner.

Reporting to the IRB Board, the Clinical Reviewer leads the primary review of safety reports, unanticipated problem reports, and audit findings, making regulatory determinations with a clinical context. Partnering with investigators, sponsors, and Board members, the reviewer provides scientific, ethical, and regulatory guidance that protects human subjects and keeps research compliant.

Primary Duties

• Provide primary review of safety reports, unanticipated problem reports, subject complaints, site visit and audit reports, and other documents that require review and regulatory determinations, with a clinical context.
• Identify problems and issues, collect additional information or request corrections, and draft memoranda or decision justifications as necessary.
• Present these issues and the clinical context for discussion at board meetings or staff meetings when appropriate.
• Provide scientific, ethical and regulatory support and advice to Board members and staff.
• Research, draft, and present reports to the Board on a wide range of topics, including investigator misconduct, site visits, FDA and sponsor audits of investigators and others, and issues involving human subjects, sponsors, and institutions.
• Convey the Board's concerns by composing written correspondence to investigators and sponsors, including requesting additional information and providing the rationale for required changes.
• Identify and assist in the resolution of problematic review items through interaction with investigators, sponsors and other IRB clients.
• Assist in performance of expedited review of protocols and other submissions, making appropriate decisions on behalf of the Board.
• Advise clients orally and in writing on applicable scientific information and regulations pertaining to human subject research, and provide guidance to help resolve scientific, ethical and regulatory issues and difficulties.
• Consult and advise clients for specific projects per contractual requirements.
• Demonstrate thought leadership in human subject protection through developing written materials (editorials, journal publications) and presenting at conferences, alone or in collaboration with colleagues.
• Remain current on medical science and regulations pertaining to human subject safety and review literature and other materials to keep abreast of developments in the regulatory, legal, and ethical arenas.

Skills & Qualifications

• Advanced scientific degree (example: Physician Assistant, Advanced Registered Nurse Practitioner, or Master in Nursing in Clinical Trials Research).
• Commitment to passing the CIP exam within 2 years of reaching the minimum qualification of 2 years with an IRB and maintaining CIP certification.
• 2 or more years of clinical experience, with prior experience in clinical research preferred.
• Familiarity with mathematical concepts such as probability and statistical inference, and with common statistical tests, correlation, confidence intervals, and survival curves in discussing the design and interpretation of human subject research.
• Ability to read, analyze, and interpret common scientific and technical journals and legal documents.
• Ability to write presentations and articles for publication that conform to prescribed style and format.
• Ability to utilize computers effectively for common office functions, with knowledge of MS Word, MS Excel, MS Outlook and MS Windows.
• Ability to effectively present information and respond to common inquiries or complaints from customers, regulatory agencies, or members of the community.
• Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems and deal with a variety of abstract and concrete variables.

Sitting at the intersection of clinical assessment and utilization review, the Clinical Reviewer builds medical necessity determinations by interpreting patient records against criteria and referring cases to physician consultants when needed. Operating across internal and external customer relationships within a utilization review operation, the reviewer maintains HIPAA confidentiality and accurate data abstraction so that care approvals remain timely, well documented, and aligned with NCQA/URAC standards.

Duties

• Review and interpret patient records against criteria to determine medical necessity and appropriateness of care, and determine if the medical record documentation supports the need for services.
• Determine approval or initiate a referral to the physician consultant, and process physician consultant decisions, ensuring the reason for denial is described in sufficient detail on correspondence.
• Abstract review-related data/information accurately and timely on the appropriate review tool and submit all administrative and review-related documents to appropriate parties.
• Perform ongoing reassessment of the review process to offer opportunities for improvement and/or change.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Attend training and scheduled meetings and maintain and use current/updated information for review.
• Maintain medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies.
• Utilize proper telephone etiquette and judicious use of other verbal and written communications, following company policies, procedures and guidelines.
• Actively cross-train to perform duties of other contracts within the company network to provide a flexible workforce to meet client/consumer needs.

Requirements

• Graduation from an accredited Master's Degree Program.
• Active LCPC and/or LCSW.
• Minimum of one year of UR and/or Prior Authorization or related experience.
• For BH Programs, minimum 3 years of direct behavioral/mental health experience in a clinical setting or other applicable State and/or Compact State clinical experience or license per contract requirements.
• Knowledge of current NCQA/URAC standards strongly preferred.
• Knowledge of the organization of medical records, medical terminology, and disease process.
• Medical record abstracting skills and strong clinical assessment and critical thinking skills.
• Proficiency in Microsoft Office and internet/web navigation.
• Excellent verbal and written communication skills, flexibility, and strong organizational skills.

A key member of the utilization management team, the Clinical Reviewer-LPN delivers medical necessity decisions for services and devices by evaluating referrals and clinical information against established criteria. Collaborating across clinical staff, including the Medical Director and department care coordinators, the reviewer ensures decisions meet contractual and regulatory turnaround standards, supporting timely patient access to care.

Functions

• Perform an initial evaluation of referral appropriateness for services and review for information needed to make a medical necessity determination.
• Request additional clinical information when needed to render a decision and determine next steps.
• Use clinical expertise to review clinical information and clinical criteria to determine if the service/device meets medical necessity for the patient.
• Ensure case review and elevation are completed within contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
• Interact with the Medical Director as needed to ensure proper medical necessity decisions are made in a timely manner.
• Act as a clinical resource to department care coordinators, providing expertise and clinical support.
• Develop and maintain a working knowledge of all services/guidelines/policies and access contract information, including contract terms, as appropriate.
• Manage multiple tasks, remain detail-oriented and responsive, and demonstrate independent thought and critical thinking.
• Review and adhere to all Company policies and procedures and the Employee Code of Conduct.

Experience & Qualifications

• Associate's Degree or Diploma in Nursing/Practical Nursing.
• Registered Nurse/LPN/LVN licensure in the state(s) of practice (based on allowable state practice act) during time of employment, with a current and unrestricted license (no blemishes on license allowed).
• Minimum of 2 years of experience in a clinical setting, with prior utilization management/review experience preferred.
• Background in clinical review, utilization review, utilization management, home health, Durable Medical Equipment, acute care, and managed care.
• Broad knowledge of health care delivery/managed care regulations, contract terms/stipulations, and governmental home health agency regulations preferred.
• Familiarity with McKesson, InterQual, MCG, and Milliman.
• Excellent negotiation, communication, problem-solving, and decision-making skills preferred.