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Clinical Utilization Review Jobs (NOW HIRING)

Mindful Health

Utilization Review Specialist

$25 - $30/hr

We believe that health encompasses the whole person, mind, and body, and our clinical programming ... Utilization Review Specialist: Responsible for ensuring adherence to Mindful Health's utilization ...

Dane Street, LLC

Utilization Review Physician

DRG validation and clinical review * Benefit and coverage determinations * Experimental ... Prior utilization review experience, preferably in a health plan or IRO environment * Familiarity ...

Southeast Health

Utilization Review Nurse

Dothan, AL · On-site

Summary The Utilization Review Nurse screens medical records in accordance with contractual ... Clinical knowledge and experience in the care of patients with multiple and complex diagnoses ...

Genesis HealthCare

The Utilization Review (UR) Analyst is responsible for assuring insurance notification ... They assure all clinical reviews are submitted to third party payors for timely and accurate ...

Shannon Health

Utilization Review Nurse

Big Spring, TX · On-site

Required * Five years of experience in Clinical Nursing * Preferred * Three years of experience in Inpatient Utilization Review Certification/Licensure: * Required * Registered Nurse (RN), with ...

ERC Pathlight

Utilization Review Manager

Aspen, CO · Hybrid

This role coordinates with Clinical Managers and Directors, Physicians, Business Office, and Managed Care Organizations to assure the smooth operation of Utilization Review functions and the ...

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Clinical Utilization Review information

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How much do clinical utilization review jobs pay per hour?

As of Jun 9, 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 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 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 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.

More about Clinical Utilization Review jobs
What cities are hiring for Clinical Utilization Review jobs? Cities with the most Clinical Utilization Review job openings:
What states have the most Clinical Utilization Review jobs? States with the most job openings for Clinical Utilization Review jobs include:
What job categories do people searching Clinical Utilization Review jobs look for? The top searched job categories for Clinical Utilization Review jobs are:
Clinical Utilization Review jobs near you
Infographic showing various Clinical Utilization Review job openings in the United States as of May 2026, with employment types broken down into 6% Locum Tenens, 17% As Needed, 60% Full Time, 6% Part Time, and 11% Contract. Highlights an 89% Physical, 2% Hybrid, and 9% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Utilization Review Specialist

Utilization Review Specialist

BriteLife Recovery

Englewood, NJ • On-site

Full-time

Posted 14 days ago

Job description

) What you will be doing?
The Utilization Review (UR) Specialist is a critical member of the administrative team at Advanced Revenue Solutions and is responsible for overseeing and coordinating all aspects of utilization review and insurance authorization for clients receiving substance use disorder (SUD) treatment at Britelife Recovery. This role ensures timely approvals and continued stay authorizations from insurance payers by effectively communicating clinical information and advocating for appropriate levels of care.
The UR Specialist works closely with clinical staff, admissions, medical providers, and third-party payers to support patient access to treatment and maintain financial viability for the organization. Success in this role requires strong clinical judgment, documentation skills, familiarity with ASAM criteria, and a working knowledge of insurance guidelines specific to behavioral health
What tasks are required?
  • Conduct initial and concurrent reviews for detox, residential, partial hospitalization (PHP), and intensive outpatient (IOP) levels of care.
  • Obtain prior authorizations and continued stay approvals from commercial and other payers by submitting timely clinical reviews and documentation.
  • Communicate clinical necessity of services based on ASAM criteria and DSM-5 diagnoses.
  • Track and document all insurance-related communications, decisions, and outcomes in the EHR and UR logs.
  • Collaborate with clinicians, therapists, case managers, and medical staff to gather accurate and up-to-date clinical information for reviews.
  • Ensure treatment plans, progress notes, and assessments are completed on time and accurately reflect medical necessity.
  • Participate in multidisciplinary team meetings to stay informed on client progress and treatment goals.
  • Assist staff with proper documentation practices to support insurance justification and compliance.
  • Maintain compliance with payer policies, HIPAA regulations, and internal utilization management protocols.
  • Monitor trends in denials, approvals, and length-of-stay metrics to support organizational performance improvement.
  • Assist in appeals and peer reviews by gathering required documentation and preparing clinical summaries.
  • Provide training and support to staff on documentation best practices related to utilization review.
  • Special projects as assigned

What we need from you?
  • Minimum of 2-3 years of experience in utilization review, case management, or insurance coordination in a behavioral health or substance use treatment setting.
  • Knowledge of ASAM criteria and levels of care for substance use and co-occurring disorders.
  • Familiarity with managed care principles, insurance authorizations, and payer requirements.
  • Bachelor's degree in Nursing, Social Work, Psychology, or a related field required; advanced degree or licensure (e.g., RN, LCSW, LPC, LMHC, or CADC) preferred.
  • Excellent organizational, communication, and time management skills.
  • Proficiency in Electronic Health Records (EHRs), insurance portals, and Microsoft Office tools.
  • Bachelor's degree in Nursing, Social Work, Psychology, or a related field required; advanced degree or licensure (e.g., RN, LCSW, LPC, LMHC, or CADC) preferred.
  • Experience or working knowledge with Collaborative MD and KIPU
  • Experience in detox and residential SUD programs.
  • Knowledge of major insurance provider platforms (e.g., Optum, Aetna, BCBS, Cigna).
  • Strong clinical writing skills and familiarity with medical necessity language.
  • Ability to advocate for clients while balancing payer relationships and compliance.
  • Ability to lift up to 25 pounds.
  • Ability to walk up and down stairs during emergency drills or situations.

All ARS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. ARS 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.

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