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Authorization Utilization Review Jobs in Virginia

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

... authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection ...

Summit BHC

Utilization Specialist - Acute

Williamsburg, VA · On-site

$24 - $28/hr

  • Medical

  • Dental

  • Vision

  • PTO

... authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection ...

UHS

UTILIZATION COORDINATOR

Danville, VA

... the authorizations for residents in treatment. · Ensures coordinated effective resident care ... review and respond to concerns expressed by customers. Together with the appropriate Department ...

Humana

Compliance UM Nurse (Wed - Sun)

Richmond, VA · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Become a part of our caring community The Compliance Nurse 2 reviews utilization management ... expedited authorization requests. Use your skills to make an impact Required Qualifications

UHS

UR COORDINATOR

Danville, VA · On-site

$26 - $35/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... authorizations for residents in treatment. • Ensures coordinated effective resident care ... Assist in preparing Utilization Review Reports as necessary. • Coordinates and makes ...

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Authorization Utilization Review information

What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?

To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.

What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?

Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.

What is the difference between Authorization Utilization Review vs Claims Reviewer?

AspectAuthorization Utilization ReviewClaims Reviewer
CredentialsTypically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionalsOften requires similar credentials, focusing on insurance policies and claims processing
Work EnvironmentHospitals, insurance companies, healthcare facilitiesInsurance companies, third-party administrators, healthcare organizations
Industry UsageUsed to assess medical necessity before approving servicesUsed to evaluate claims for payment accuracy and compliance

Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.

What is authorization utilization review?

Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.
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What job categories do people searching Authorization Utilization Review jobs in Virginia look for? The top searched job categories for Authorization Utilization Review jobs in Virginia are:
What cities in Virginia are hiring for Authorization Utilization Review jobs? Cities in Virginia with the most Authorization Utilization Review job openings:
Authorization Utilization Review jobs near you
Infographic showing various Authorization Utilization Review job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 85% Full Time, 12% Part Time, and 2% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

Clinical Authorization Specialist Utilization Review

HALLMARK YOUTHCARE RICHMOND INC

Richmond, VA • On-site

Other

Medical, Retirement

Re-posted 21 hours ago

Job description

As a leading Residential Treatment Center in the Greater Richmond area, Hallmark Youthcare treats adolescents with emotional and behavioral challenges triggered by trauma. Treatment is provided in a warm and friendly environment by a group of well-trained, highly motivated staff that take pride in delivering quality care in a fast-paced environment.

We are seeking a detail-oriented Clinical Authorization Specialist (Utilization Review) to join our healthcare team. The ideal candidate will have experience in prior authorizations, insurance verification, utilization review, and medical necessity determinations. This role is responsible for ensuring that medical services are appropriately authorized, clinically supported, and compliant with payer guidelines before, during, and after patient care.

The Clinical Authorization Specialist serves as a liaison between healthcare providers, insurance companies, and patients to facilitate timely approvals while minimizing denials and delays in care.

In addition, this role maintains communication with referral sources (CSA/FAPT/IACCT) to coordinate placement and reimbursement standards for transfers from emergency placements and document submission to Magellan for Medicaid consideration.

****Key Responsibilities

  • Master's degree in health services field.
  • Review and process prior authorization requests for medical procedures, diagnostic testing, medications, therapies, and specialty services.
  • Evaluate clinical documentation to determine medical necessity using payer guidelines, evidence-based criteria, and insurance policies.
  • Perform prospective, concurrent, and retrospective utilization reviews.
  • Communicate with physicians, nurses, case managers, and insurance representatives to obtain required clinical documentation.
  • Submit authorization requests and monitor status through payer portals and electronic health record (EHR/EMR) systems.
  • Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
  • Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
  • Maintain accurate records of all authorization activities, communications, and determinations.
  • Stay current on payer policies, CMS regulations, and utilization management best practices.
  • Assist with appeals and peer-to-peer review coordination when necessary.
  • Meet productivity, turnaround time, quality, and compliance standards.

Required Qualifications

  • High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
  • Minimum of 2 years of experience in prior authorization, utilization review, medical insurance, case management, including admissions.
  • Strong understanding of commercial insurance, Medicare, Medicaid, and managed care plans.
  • Experience working with electronic medical records (EMR/EHR) and payer authorization portals.
  • Excellent organizational, analytical, and problem-solving skills.
  • Strong verbal and written communication abilities.
  • Ability to prioritize multiple tasks in a fast-paced healthcare environment.

Benefits:

Set schedule Monday- Friday 9 am- 5pm

Full benefit package available

Matching 401K

Time off accrued each payroll

Free employee meals

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