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Authorization Utilization Review Jobs in Washington

Woodley House

Clinical Program Manager

Washington, DC · On-site

$90K/yr

Provide clinical oversight and consultation for resident care, including admissions, assessments, treatment planning, crisis intervention, case management, utilization review, authorization requests ...

Maryland Physicians Care

Medical Director

Linthicum, MD · On-site +1

$266K - $315K/yr

Provide medical support and direction to MPC MCO's Pre-Authorization Unit related to the ... Experience in utilization review and management practices, processes, and procedures. * Knowledge ...

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Authorization Utilization Review information

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.

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 are popular job titles related to Authorization Utilization Review jobs in Washington?

For Authorization Utilization Review jobs in Washington, the most frequently searched job titles are:

What job categories do people searching Authorization Utilization Review jobs in Washington look for?

The top searched job categories for Authorization Utilization Review jobs in Washington are:

Authorization Utilization Review jobs near you
Infographic showing various Authorization Utilization Review job openings in Washington as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 14% Part Time, 4% Contract, and 1% Nights. Highlights an 86% Physical, 3% Hybrid, and 11% Remote job distribution.

Case Reviewer

Absolute Staffing & Consulting Solutions

Columbia, MD

$23 - $27/hr

Full-time

Re-posted 13 days ago

Job description

Absolute Staffing & Consulting Solutions is looking for a Case Reviewer to join our team of professionals. This is a hybrid, work-from-home position for candidates residing within commuting distance of Columbia, Maryland. While the position is performed remotely Monday through Friday, employees are expected to attend quarterly in-person trainings and meetings at our client’s Columbia, MD office. If you’re looking for the flexibility of working from home while remaining connected to a collaborative team, we’d love to hear from you!


Position Summary


As a Case Reviewer, you will be responsible for performing utilization reviews to authorize services for individuals enrolled in Medicaid. The utilization review process involves applying program policies, verifying medical, technical, and financial eligibility, and reviewing medical records to issue decisions regarding pre-authorization of services. 

 

Essential Functions

  • Provides review decisions for prospective reviews based on an established set of criteria.
  • Screens situations according to specific criteria to determine if care is appropriate.
  • Refers cases that fail to meet criteria to a Registered Nurse or Social Worker reviewer.
  • Ensures review is conducted thoroughly and within specified timeframes.
  • Serves as liaison among clinical reviewer, provider, facility, and/or subscriber.
  • Documents medical information supporting decisions into the workflow documentation system, ensuring data is entered accurately and timely.
  • Ensures quality customer service by responding to email and phone inquiries from providers and consumers.


Requirements

  • Bachelor’s degree in the health or human services and at least 1 year of experience in utilization review or 1 year of experience evaluating, analyzing, researching and developing health care services, policies and programs preferred.
  • Demonstrated ability working with confidential information and in a deadline-driven environment.
  • Excellent verbal and written communication skills
  • Comfortable with completing basic math functions.
  • Attention to detail, analytical skills, and the ability to interpret medical documentation accurately.
  • Possess intermediate PC skills including navigating electronic health records and other computer software.
  • Ability to work independently and as part of a team.
  • Organizational skills and time management.
  • Experience in a community health care environment preferred.
  • Experience with utilization review of medical services preferred.
  • Satisfactory completion of medical terminology course preferred.
  • Must reside within a reasonable commuting distance of Columbia, Maryland to attend required quarterly in-person trainings and team meetings.
  • Reliable transportation to the Columbia, MD office for scheduled quarterly onsite meetings is required.

Preferred Skills and Certifications

  • Proficiency with Sharepoint
  • Possess intermediate skills in Excel
  • Strong analytical and critical thinking skills
  • Previous support planner experience a plus


Shift & Work Location

  • Monday–Friday 8:00 am- 5:00 pm EST (Remote, Work from Home)
  • Required: Quarterly attendance for in-person training sessions on site in Columbia, MD. *Advance notice will be provided for all onsite training dates


Base Pay:

$23- $27/ hour


Why work for our client?

Our client is one of the country's most respected population health management organizations. They work with state and federal government programs, as well as employers and health plans offering clinical, analytical, and technical expertise.

Health has changed a lot through our 50-year history, but what has remained constant is that they care deeply about who they serve and what they do. Their success is built on their ability to adapt, respond to client needs, and offer innovative solutions at every turn.

Our client is looking for talented individuals who not only believe in the mission, but who are ready to take ownership and make a difference in the lives of people, in the world of health.