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Insurance Utilization Review Jobs in Pittsburgh, PA

Preston Harris Group

Medical Director

West Mifflin, PA · On-site

  • Medical

  • Retirement

  • PTO

Performs medical review activities pertaining to utilization review, quality assurance, and medical ... Malpractice insurance * Paid time off * Professional development assistance Primary care ...

US Tech Solutions

Care Coordinator

Pittsburgh, PA · On-site

$24 - $25/hr

... utilization review, social services, nursing, or related healthcare fields. * Strong understanding of healthcare insurance, reimbursement, prior authorizations, and patient assistance programs.

US Tech Solutions

Care Coordinator #

Pittsburgh, PA · On-site

$24 - $25/hr

... utilization review, social services, nursing, or related healthcare fields. * Strong understanding of healthcare insurance, reimbursement, prior authorizations, and patient assistance programs.

Pittsburgh Comprehensive Treatment Center

Case Manager

Pittsburgh, PA · On-site

$19.50 - $25/hr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

Medical, Dental, and Vision insurance * Competitive 401(k) plan * Paid vacation and sick time ... Previous experience in case management and/or utilization review preferred. Licenses/Certifications:

Community LIFE

RN Case Manager

Pittsburgh, PA · On-site

$72K - $85K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Medical, dental, vision, life & disability insurance * Retirement Support: Automatic contributions ... Familiarity with managed care, quality assurance, and utilization review * Basic computer ...

Community LIFE

RN Case Manager

Homestead, PA · On-site

$72K - $85K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Medical, dental, vision, life & disability insurance * Retirement Support: Automatic contributions ... Familiarity with managed care, quality assurance, and utilization review * Basic computer ...

SPHS GROUP

Team Leader

New Kensington, PA

Conducts ongoing utilization review activities, including adherence to managed care standards ... Ability to transport oneself in an insured vehicle in the performance of essential functions.

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Insurance Utilization Review information

See Pittsburgh, PA salary details

$20

$41

$66

How much do insurance utilization review jobs pay per hour?

As of Aug 17, 2026, the average hourly pay for insurance utilization review in Pittsburgh, PA is $41.05, according to ZipRecruiter salary data. Most workers in this role earn between $32.45 and $47.16 per hour, depending on experience, location, and employer.

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.

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 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 most commonly searched types of Insurance Utilization Review jobs in Pittsburgh, PA?

The most popular types of Insurance Utilization Review jobs in Pittsburgh, PA are:

What are popular job titles related to Insurance Utilization Review jobs in Pittsburgh, PA?

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

What job categories do people searching Insurance Utilization Review jobs in Pittsburgh, PA look for?

The top searched job categories for Insurance Utilization Review jobs in Pittsburgh, PA are:

Insurance Utilization Review jobs near you
Infographic showing various Insurance Utilization Review job openings in Pittsburgh, PA as of August 2026, with employment types broken down into 1% As Needed, 73% Full Time, 22% Part Time, and 4% Contract. Highlights an 91% Physical, 1% Hybrid, and 8% Remote job distribution, with an average salary of $85,380 per year, or $41 per hour.

Medical Director/Physician Reviewer

TALENT Software Services

Pittsburgh, PA • Remote

$280K - $300K/yr

Full-time

Posted 24 days ago

Job description

Position: Medical Director
Location: Remote
Duration: Contract to Hire
Working hours: Monday to Friday - 8 hours a day

Active medical state licensure required for any of these states: PA, NY, or WV.

Medical Director Job Description

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment or service. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.

Responsibilities

Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for members and provider determination notifications, all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.

Required Qualifications

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Clinical, Direct Patient care (hospital, outpatient, or private practice)
Medical Doctor or Doctor of Osteopathic Medicine (DO)
Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Case Management, Oral & Written Communication Skills, Collaboration, Listening, Telephone Skills, General Computer Skills, Clinical Software, Managed Care

Preferred Qualifications

Master's Degree in Business Administration/Management or Public Health
Medical Management in a Health Insurance Plan; strong knowledge of the managed care industry
Experience with MCG or InterQual

Company Description

A global technology company that develops and delivers a wide range of software, cloud computing, artificial intelligence, productivity, business, and enterprise solutions. It supports organizations worldwide through platforms and services used for workplace collaboration, data management, application development, cybersecurity, and digital transformation.