Clinical Case Review Jobs
Clinical Case Review jobs are open across health insurance, managed care, hospitals, and utilization management firms, from entry-level reviewer to senior and lead roles, with specializations in medical necessity review, appeals and grievances, and concurrent review. Find a role that fits from the openings below and apply directly.
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POSITION SUMMARY
This position facilitates the analysis of medical staff quality and performance data for the organization through coordination of information including data collection, analysis and trending of required medical staff quality and peer review activities, and other select clinical outcome measurements. This position serves as assisting the medical staff with practitioner specific quality monitoring and reporting. This position manages issues that are brought up regarding the quality of practice by providers, evaluates and investigates quality issues. Responsible for managing Ongoing Professional Practice Evaluations/Focused Professional Practice Evaluations. Supporting the Peer Review Committee and other Quality related projects. This Registered Nurses will be evaluating the quality and appropriateness of care provided by their peers, aiming to improve patient safety and practice standards through a non-punitive, continuous learning process. The role of the Case Review RN is to establish, promote and monitor seamless care for TCRHCC patients.
Qualifications:Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare.
License:
A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Experience:
Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Accessing community resources for patient referrals
- Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal review.
- Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors.
- Knowledge of diagnosis related groups (DRG) and documentation requirements
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Reliable and dependable; reports to work as scheduled without excessive absences
- Ability to sense varying skill levels and direct instruction accordingly
- Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
- Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
- Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
- Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
- Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
- Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.
Mental:
The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work.
Environmental:
The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.
- Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care
- Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division.
- Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided.
- Perform chart reviews to identify quality, timeliness, and appropriateness of patient care.
- Refer cases as appropriate to physician advisors for review and determination.
- Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
- Prior experience in hospital or clinical management preferred.
- Requires computer knowledge.
- Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications.
- Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff.
- Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff.
- Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities.
- Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
- Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care.
- Assists with review, research, and decision of first level appeal process with Purchase Referred Care
- Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
- Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer
- Performs other assigned duties as needed
POSITION SUMMARY
This position facilitates the analysis of medical staff quality and performance data for the organization through coordination of information including data collection, analysis and trending of required medical staff quality and peer review activities, and other select clinical outcome measurements. This position serves as assisting the medical staff with practitioner specific quality monitoring and reporting. This position manages issues that are brought up regarding the quality of practice by providers, evaluates and investigates quality issues. Responsible for managing Ongoing Professional Practice Evaluations/Focused Professional Practice Evaluations. Supporting the Peer Review Committee and other Quality related projects. This Registered Nurses will be evaluating the quality and appropriateness of care provided by their peers, aiming to improve patient safety and practice standards through a non-punitive, continuous learning process. The role of the Case Review RN is to establish, promote and monitor seamless care for TCRHCC patients.
Qualifications:Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare.
License:
A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Experience:
Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Accessing community resources for patient referrals
- Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal review.
- Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors.
- Knowledge of diagnosis related groups (DRG) and documentation requirements
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Reliable and dependable; reports to work as scheduled without excessive absences
- Ability to sense varying skill levels and direct instruction accordingly
- Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
- Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
- Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
- Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
- Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
- Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.
Mental:
The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work.
Environmental:
The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.
- Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care
- Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division.
- Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided.
- Perform chart reviews to identify quality, timeliness, and appropriateness of patient care.
- Refer cases as appropriate to physician advisors for review and determination.
- Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
- Prior experience in hospital or clinical management preferred.
- Requires computer knowledge.
- Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications.
- Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff.
- Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff.
- Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities.
- Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
- Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care.
- Assists with review, research, and decision of first level appeal process with Purchase Referred Care
- Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
- Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer
- Performs other assigned duties as needed
Clinical Case Review Jobs by Experience Level
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Find Clinical Case Review JobsClinical Case Review Job Market
Who's Hiring
- American Traveler49
- INTEGRIS Health2
- Loretto Hospital2
- CorVel Corporation2
- Memorial Healthcare System2
Top Industries Hiring
- Healthcare & Medical Services
- Medical Devices
- Technology & Software
What Employers Look For
The qualifications that appear most often in clinical case review jobs.
- Active RN or licensed clinical professional credential with current state licensure
- Experience applying InterQual or MCG clinical criteria for medical necessity determinations
- Minimum two years of acute care, managed care, or utilization management experience
- Familiarity with payer guidelines, CMS regulations, and coverage determination standards
- Proficiency with electronic health record systems and case management platforms
- Strong written communication skills for producing defensible, compliant review documentation
Tips for Your Clinical Case Review Job Search
Tailor your resume to UR criteria
Hiring managers for clinical case review roles scan for InterQual or MCG criteria experience before anything else. Name the specific criteria sets you've used, the clinical settings you applied them in, and whether your reviews were prospective, concurrent, or retrospective.
Highlight your licensure and specialty clearly
Many postings filter by licensure type before a human reads your resume. Put your RN, LCSW, or other active license and state of issue near the top. If you hold licensure in multiple states, list each one so you don't get screened out of remote roles unnecessarily.
Apply early to roles that fit
Migrate Mate lists clinical case review openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Filter openings by review type first
Utilization management, appeals, peer-to-peer facilitation, and quality improvement reviews require different daily workflows. Before applying, confirm which review type the role centers on so your cover letter can speak directly to that workflow and avoid a mismatch at the interview stage.
Prepare a peer-to-peer scenario for interviews
Interviewers routinely ask how you handle a physician who pushes back on a denial. Prepare a specific, de-identified example where you communicated a determination professionally and reached a documented resolution. Vague answers about staying calm rarely satisfy clinical case review hiring panels.
Negotiate remote arrangements before accepting
Remote and hybrid clinical case review roles often have state-of-licensure restrictions built into the offer. Clarify which states you're authorized to review cases for, whether the arrangement is permanent or subject to change, and whether you'll be expected to travel for audits or team meetings.
Clinical Case Review Jobs: Frequently Asked Questions
Which companies are hiring the most clinical case reviews?
The companies hiring the most clinical case reviews right now include American Traveler, INTEGRIS Health, and Loretto Hospital, with the largest share of openings in California, Florida, and Oregon, based on current listings on Migrate Mate as of November 2026. Health insurance carriers and large managed care organizations consistently account for the majority of postings.
How many clinical case review jobs are remote?
About 55% of clinical case review openings are fully remote or hybrid as of November 2026, making it one of the more remote-accessible clinical roles available. Utilization management and appeals review positions are the sub-areas most frequently posted as fully remote, while concurrent review roles tied to inpatient settings tend to require on-site or hybrid arrangements.
How do you become a clinical case review?
Start by earning an active clinical license, most commonly as a registered nurse or licensed social worker, alongside direct patient care experience in an acute or post-acute setting. From there, build familiarity with InterQual or MCG criteria, either through employer training or self-study. Pursue a case management certification such as CCM or CPUR to strengthen your candidacy, then target entry-level utilization review or case management roles that provide structured review experience before moving into dedicated clinical case review positions.
Can you get a clinical case review job with limited experience?
Yes, some employers hire clinicians into clinical case review with as little as one year of direct patient care experience, particularly for roles focused on specific service lines where your clinical background is a direct match. Strengthening your application with demonstrated knowledge of payer processes, coverage criteria, or discharge planning significantly offsets a shorter work history. Entry-level utilization review coordinator roles are the most practical starting point and often lead directly into case review responsibilities.
What does the clinical case review interview process look like?
Most clinical case review interviews include an initial recruiter screen focused on licensure and criteria experience, followed by a structured panel or one-on-one interview with a clinical supervisor or medical director. You'll typically be asked to walk through a real or hypothetical case determination, explain your rationale against established criteria, and describe how you handle physician disagreements. Some employers add a written or scenario-based assessment before making an offer.
Where can I find and apply to clinical case review jobs?
You can find and apply to clinical case review jobs on Migrate Mate, which lists current openings from across the United States. Search the listings to find roles that match your licensure, specialty, and preferred work arrangement, then apply directly to each position that fits.
See All 80 Clinical Case Review Jobs
Find roles that match your experience and apply in just a few clicks.
Find Clinical Case Review Jobs