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Clinical Utilization Review Jobs in Riverside, CA

KPC Health

Utilization Review RN

Santa Ana, CA · On-site

Utilization Review RN The Utilization Review RN reviews client health records to ensure proper ... Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and ...

KPC Global MSO

Utilization Review RN

Santa Ana, CA · On-site

SUMMARY The Utilization Review RN reviews client health records to ensure proper utilization of ... Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and ...

Corvel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · Remote

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity ...

Corvel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · On-site

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity ...

CorVel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · On-site

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity ...

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

The methodology is designed to facilitate and insure the achievement of quality, clinical and cost ... At least 3 years of experience in utilization review, referrals, authorizations, denials and ...

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

The methodology is designed to facilitate and insure the achievement of quality, clinical and cost ... At least 3 years of experience in utilization review, referrals, authorizations, denials and ...

Acadia Healthcare

Utilization Specialist PRN

Riverside, CA · On-site

$31 - $50/hr

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance ...

Acadia Healthcare

Utilization Specialist PRN

Riverside, CA · On-site

$31 - $50/hr

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance ...

Pacific Grove

Utilization Specialist PRN

Riverside, CA · On-site

$31 - $50/hr

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance ...

TotalMed RN

Travel Utilization Review RN

Irvine, CA · On-site

Utilization Review * Discipline: RN * Duration: 13 weeks * 40 hours per week * Shift: 8 hours, days ... clinicians of all specialties in all 50 states. They offer local and travel jobs and match ...

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Clinical Utilization Review information

See Riverside, CA salary details

$22

$44

$71

How much do clinical utilization review jobs pay per hour?

As of Sep 10, 2026, the average hourly pay for clinical utilization review in Riverside, CA is $44.11, according to ZipRecruiter salary data. Most workers in this role earn between $34.86 and $50.67 per hour, depending on experience, location, and employer.

What is clinical utilization review?

Clinical utilization review is a process in healthcare that evaluates the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. Utilization review professionals assess patient records and treatment plans to ensure that care provided is medically necessary and aligns with established guidelines. This process helps control healthcare costs, improves quality of care, and ensures compliance with insurance or regulatory requirements. Utilization review can be done prospectively, concurrently, or retrospectively, depending on the stage of patient care.

What are the key skills and qualifications needed to thrive as a clinical utilization review specialist, and why are they important?

To thrive as a Clinical Utilization Review specialist, you need a strong background in nursing or healthcare, knowledge of medical terminology, and often an RN or relevant clinical license. Familiarity with utilization management software, healthcare regulations, and medical coding systems such as ICD-10 and CPT is typically required. Analytical thinking, attention to detail, and strong communication skills help professionals collaborate with care teams and explain decisions clearly. These competencies ensure effective review of medical necessity, regulatory compliance, and optimized patient care outcomes.

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

Clinical Utilization Review professionals often face challenges such as balancing the need for cost-effective care with ensuring patients receive appropriate services, managing tight deadlines, and navigating complex insurance requirements. Effective communication with healthcare providers and payers is crucial, as is staying up-to-date with regulatory guidelines. Developing strong organizational skills and maintaining a collaborative approach with interdisciplinary teams can help address these challenges and support successful case outcomes.

What is the difference between Clinical Utilization Review vs Medical Reviewer?

AspectClinical Utilization ReviewMedical Reviewer
CredentialsRN, LPN, or other healthcare professionals with clinical licensesLicensed physicians, often MDs or DOs
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, insurance companies, or healthcare organizations
Primary FocusAssessing medical necessity and appropriateness of careProviding expert medical opinions and final review decisions
Common UsageInvolved in reviewing cases for insurance authorizationMaking clinical determinations on coverage and treatment

While both roles involve reviewing medical cases, Clinical Utilization Review professionals focus on evaluating the necessity of care based on clinical guidelines, often working within insurance or healthcare organizations. Medical Reviewers, typically licensed physicians, provide expert medical opinions and make final coverage decisions. Both roles require healthcare credentials and aim to ensure appropriate patient care and cost management, but their scope and responsibilities differ slightly.

What cities near Riverside, CA are hiring for Clinical Utilization Review jobs?

Cities near Riverside, CA with the most Clinical Utilization Review job openings:

Clinical Utilization Review jobs near you
Infographic showing various Clinical Utilization Review job openings in Riverside, CA as of September 2026, with employment types broken down into 50% Full Time, and 50% Contract. Highlights an 50% In-person, and 50% Remote job distribution, with an average salary of $91,752 per year, or $44.1 per hour.

Utilization Review RN

Santa Ana, CA • On-site

KPC Health
Health Care and Social Assistance • 201 - 500 employees
Learn more about KPC Healthexternal

Other

Posted 6 days ago

Job description

Utilization Review RN

The Utilization Review RN reviews client health records to ensure proper utilization of treatment resources.

Responsibilities And Duties:
  • Coordinates and reviews all medical records, as assigned to caseload.
  • Actively participates in Case Management and Treatment Team meetings
  • Serves as on-going educator to all departments.
  • Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from fiscal intermediary; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting
  • Able to work independently and use sound judgment.
  • Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
  • Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families.
  • Performs other duties as assigned.

This position is a mid-shift (3pm - 11:30pm) and will need to work on weekends.

Education & Experience Requirements:
  • Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.
  • CA RN License Required
  • Minimum of 2 years' experience with the population of the facility and previous experience in utilization management preferred.
Skills & Abilities Requirements:
  • Communication
  • Planning & Organizing
  • Problem Solving
  • Attention to Detail
Physical Requirements:
  • Body Positions: Sitting and standing for prolonged periods.
  • Body Movements: Arm and hand dexterity.
  • Body Senses: Must have command of close and distant sight, color perception and hearing.
  • Strength: Ability to lift and move up to 25-pounds.
Working Environment:
  • Work in an office, where the climate is controlled.
  • OSHA exposure category: I
  1. Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
  2. Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
  3. Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.
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About KPC Health

Sourced by ZipRecruiter

KPC Health has an integrated approach to serving the people of Riverside, San Bernardino and Orange County. Our acute care medical centers provide high quality, comprehensive and affordable healthcare for the entire family. For us, healthcare is not just about caring for our patients, but also about investing in the people throughout our communities. We are one team with one mission and that mission is for all our patients, and their families to Enjoy Life in Great Health.

Industry

Health care and social assistance

Company size

201 - 500 Employees

Headquarters location

Santa Ana, CA, US

Year founded

2004

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