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Insurance Utilization Review Jobs in Pennsylvania

Acadia Healthcare

Utilization Specialist

Moosic, PA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...

Acadia Healthcare

Utilization Specialist

Allenwood, PA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...

ABHS

RB Primary Therapist

Scranton, PA · On-site

$60K - $75K/yr

Ensure all documentation supports the "Medical Necessity" of the residential level of care for insurance utilization reviews (UR). 4. Multidisciplinary Collaboration * Participate in weekly Treatment ...

Emergitel HR Solutions

RN - Case Manager

Honesdale, PA · On-site

$2.5K/wk

Utilization Review / Case Manager RN Location: Honesdale, Pennsylvania 18431 Department: Case ... Facilitate communication among providers, patients, and insurance companies. * Coordinate discharge ...

emergiTEL HR Solutions

RN - Case Manager

Honesdale, PA · On-site

$2.5K/wk

Utilization Review / Case Manager RN Location: Honesdale, Pennsylvania 18431 Department: Case ... Facilitate communication among providers, patients, and insurance companies. * Coordinate discharge ...

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Insurance Utilization Review information

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How much do insurance utilization review jobs pay per hour?

As of Aug 19, 2026, the average hourly pay for insurance utilization review in Pennsylvania is $42.38, according to ZipRecruiter salary data. Most workers in this role earn between $33.51 and $48.65 per hour, depending on experience, location, and employer.

What is an insurance utilization review?

An Insurance Utilization Review job involves evaluating medical treatments and services to determine if they are necessary, appropriate, and covered by a patient's insurance plan. Professionals in this role review medical records, treatment plans, and insurance policies to ensure compliance with guidelines and cost-effectiveness. They work closely with healthcare providers, insurance companies, and patients to facilitate approvals or appeals. The goal is to balance quality patient care with cost containment in the healthcare system.

What are the key skills and qualifications needed to thrive in insurance utilization review?

To thrive in Insurance Utilization Review, you generally need a strong background in healthcare or nursing, an understanding of medical terminology, and analytical thinking skills, often supported by an RN license or relevant clinical experience. Familiarity with utilization management software, coding systems like ICD-10, and knowledge of regulatory requirements (such as Medicare or Medicaid) are important. Strong communication, attention to detail, and problem-solving abilities help professionals excel when interacting with providers and insurers. These skills are essential to ensure appropriate care is authorized while maintaining regulatory compliance and cost-effectiveness.

What are the most common challenges faced by insurance utilization review professionals?

One common challenge in Insurance Utilization Review is balancing the need for cost-effective care with the clinical needs of patients, which often requires careful analysis and decision-making. Professionals in this role frequently navigate complex medical records, strict policy guidelines, and collaborate with healthcare providers who may advocate strongly for particular treatments. Managing challenging conversations while maintaining professionalism and ensuring timely determinations are also a regular part of the role. Developing expertise in these areas can make the job both demanding and rewarding, while building a strong foundation for career growth within healthcare administration.

How do I get into an insurance utilization review?

To become an insurance utilization review specialist, candidates typically need a background in healthcare, nursing, or a related field, along with knowledge of insurance policies and medical terminology. Certification such as the Certified Professional in Healthcare Quality (CPHQ) or similar credentials can enhance job prospects. Relevant skills include attention to detail, analytical thinking, and familiarity with medical records and insurance software systems.

Is insurance utilization review a stressful job?

Insurance utilization review can be stressful due to the need for accuracy, attention to detail, and meeting strict deadlines. Reviewers often handle complex cases and must balance policy guidelines with patient needs, which can contribute to job pressure. However, the level of stress varies depending on workload, work environment, and individual coping skills.

What are the most commonly searched types of Insurance Utilization Review jobs in Pennsylvania?

The most popular types of Insurance Utilization Review jobs in Pennsylvania are:

What are popular job titles related to Insurance Utilization Review jobs in Pennsylvania?

For Insurance Utilization Review jobs in Pennsylvania, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Review jobs in Pennsylvania look for?

The top searched job categories for Insurance Utilization Review jobs in Pennsylvania are:

What cities in Pennsylvania are hiring for Insurance Utilization Review jobs?

Cities in Pennsylvania with the most Insurance Utilization Review job openings:

Insurance Utilization Review jobs near you
Infographic showing various Insurance Utilization Review job openings in Pennsylvania as of August 2026, with employment types broken down into 1% As Needed, 70% Full Time, 25% Part Time, and 4% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution, with an average salary of $88,158 per year, or $42.4 per hour.

Utilization Specialist

Acadia Healthcare

Moosic, PA • On-site

Full-time

Posted 9 days ago

Acadia Healthcare rating

6.2

Company rating: 6.2 out of 10

Based on 190 frontline employees who took The Breakroom Quiz

699th of 888 rated healthcare providers

Job description

Overview
PURPOSE STATEMENT:
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
Responsibilities
ESSENTIAL FUNCTIONS:
  • Act as liaison between managed care organizations and the facility professional clinical staff.
  • Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
  • Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
  • Conduct quality reviews for medical necessity and services provided.
  • Facilitate peer review calls between facility and external organizations.
  • Initiate and complete the formal appeal process for denied admissions or continued stay.
  • Assist the admissions department with pre-certifications of care.
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS:
  • Perform other functions and tasks as assigned.

Qualifications
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
  • Required Education: High school diploma or equivalent.
  • Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
  • Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred

LICENSES/DESIGNATIONS/CERTIFICATIONS:
  • Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
  • CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
  • First aid may be required based on state or facility requirements.

ADDITIONAL REGULATORY REQUIREMENTS:
While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances
(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.
GBHNE

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About Acadia Healthcare

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Acadia Healthcare is a leading provider in the healthcare and hospital industry, based in Franklin, Tennessee, United States. The company is recognised for its commitment to creating a behavioural health network that provides accessible, high-quality treatment options for individuals suffering from mental health issues, addiction, eating disorders, and PTSD. Acadia Healthcare was founded in 2005, with the mission to create a world-class organization that sets the standard of excellence in the treatment of specialty behavioural health and addiction disorders.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Franklin, TN, US

Year founded

2005

Social media

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