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Clinical Utilization Review Jobs (NOW HIRING)

UHS

PR · On-site

The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization ...

Fusion HCR

Utilization Review Nurse

Las Vegas, NV · On-site

This role works closely with clinical teams to ensure efficient resource utilization and quality patient outcomes. Responsibilities * Review admissions using InterQual and/or Milliman criteria

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

Utilization Review Nurse Responsible for determining the appropriateness of hospital admission ... Responsible for working with the Clinical Care Coordinator and Complex Care Manager to facilitate ...

Washington Hospital

Utilization Review Liaison

Fremont, CA · On-site

$32.35 - $43.63/hr

... the Utilization Review (UR) Liaison is responsible for the assisting Utilization Review Case ... Continue to learn about clinical programs, processes, and changes May also perform office support ...

Wvumedicine

Clinical Utilization Management Pharmacist

$121K - $144K/yr

Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals ...

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

Responsible for working with the Clinical Care Coordinator and Complex Care Manager to facilitate ... to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND ...

US Tech Solutions

Utilization Review Nurse

Canton, MA · On-site

$55 - $60/hr

Review clinical documentation and determine benefit eligibility using evidence-based clinical ... Ensure all utilization review activities meet regulatory turnaround time requirements.

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

Responsible for working with the Clinical Care Coordinator and Complex Care Manager to facilitate ... to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND ...

WVU Medicine

Clinical Utilization Management Pharmacist

$121K - $144K/yr

Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals ...

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Clinical Utilization Review information

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How much do clinical utilization review jobs pay per hour?

As of Sep 10, 2026, the average hourly pay for clinical utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 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.

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Cities with the most Clinical Utilization Review job openings:

What states have the most Clinical Utilization Review jobs?

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What are popular job titles related to Clinical Utilization Review jobs?

For Clinical Utilization Review jobs, the most frequently searched job titles are:

Clinical Utilization Review jobs near you
Infographic showing various Clinical Utilization Review job openings in the United States as of August 2026, with employment types broken down into 3% As Needed, 74% Full Time, 15% Part Time, and 8% Contract. Highlights an 85% Physical, 1% Hybrid, and 14% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

DIRECTOR - UTILIZATION REVIEW

PR • On-site

UHS
Health Care and Social Assistance • 10K+ employees
Learn more about UHSexternal

Full-time

Re-posted 25 days ago

Universal Health Services rating

6.8

Company rating: 6.8 out of 10

Based on 255 frontline employees who took The Breakroom Quiz

Job description

Responsibilities
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization reviews, organization determinations and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensure that denial and appeal letters are responded to in accordance with industry standards .
Responsibilities and essential duties:
  • Oversee Utilization Review Processes:
  • Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with clinical protocols, and organizational policies.
  • Keep abreast of any legal or regulatory changes that impact on the UR functions and operations to ensure timely implementation.
  • Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines.
  • Conduct regular audits of utilization reviews to ensure adherence to policies and procedures, documentation of cases in established tools, use of best practices, and ethical standards.
  • Available daily for case analysis, as required.
  • Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards.
  • Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services.
  • Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management.
  • Ensure Compliance and Quality Control
  • Provides assertive, effective, and consistent supervision to assure quality control and service excellence.
  • Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments.
  • Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation.
  • Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards.
  • Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets.
  • Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC.
  • Supervises the Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director.
  • Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care.
  • Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement.
  • Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others.
  • Responsible for conducting internal audits within UR Department.
  • Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs.
  • Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements.
  • Training and Development
  • Train UR staff and psychiatrists in the best practices, regulatory requirements, and documentation standards.
  • Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
  • Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees.
  • Encourages the staff attendance and participation to the educational activities.
  • Communication
  • Demonstrates effective communication skills and reports to the VP of Clinical Affairs.
  • Maintains open communication with peers and the staff.
  • Keeps the staff informed about changes or situations related to department processes.
  • Meet with staff on a regular basis, one on one, and conduct monthly meetings or as needed.
  • Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes.
  • Communicate with patients and families about treatment options and the rationale for service denials, when appropriate.
  • Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions.
  • Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system.
  • Works in collaboration with other departments of the organization.
  • Represents the organization in different activities and meetings.
  • Develop and Implement Policies
  • In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan.
  • Establish and update UR policies and procedures to optimize services and resource use.
  • Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments.
  • Effectively manages staff related matters in accordance with the rules, personnel policies and procedures.
  • Develops an annual vacation plan taking into consideration the service needs and the employees requests.
  • Keeps the specialization license and professional association membership ( colegiación ) effective as it corresponds to the specialization, if apply.
  • Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.

    • EEO Statement
    All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
    Notice
    At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating highly efficient and best-in-class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.
    Qualifications
      • Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
      • Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling in the relevant jurisdiction.
      • Professional associating membership ( colegiación ): Valid membership for Social Work and Psychiatric Nursing
      • A minimum of five years' experience in the mental health field, working directly with patients or in clinical services supervision. Three or more years of experience in a leadership role specifically in the utilization review area or in mental health case management field .
      • Require knowledge in Microsoft Office
      • Fully Bilingual

    What Universal Health Services employees say

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    About Universal Health Services

    Sourced by ZipRecruiter

    Universal Health Services (UHS) is a major player in the healthcare industry, based in King of Prussia, Pennsylvania, U.S. Founded in 1978, UHS offers hospital and healthcare services. Their diverse services range from acute care hospitals, behavioral health facilities and ambulatory centers nationwide. The company's mission of enhancing the health and well-being of their patients is reflected in their commitment to 'Helping Individuals Live Longer, Healthier and Happier Lives'. Universal Health Services' consistent growth and success in their industry have been recognized on numerous occasions, including being ranked amongst the Fortune 500 list of largest companies.

    Industry

    Health care and social assistance

    Company size

    10,000+ Employees

    Headquarters location

    King of Prussia, PA, US

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