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Insurance Utilization Reviewer Jobs (NOW HIRING)

Enlyte

Utilization Reviewer 2

Tampa, FL

$59K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Enlyte

Utilization Reviewer 2

Tampa, FL · On-site

$59K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Genex Services

Utilization Reviewer 2

Tampa, FL · On-site

$59K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Enlyte

Utilization Reviewer 2

Wayne, PA · On-site

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Genex Services

Utilization Reviewer 2

Wayne, PA · On-site

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

New

Enlyte

Utilization Reviewer 2

Saint Louis, MO · On-site

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Genex Services

Utilization Reviewer 2

Saint Louis, MO · On-site

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

New

Enlyte

Utilization Reviewer 2

Wayne, PA

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Enlyte

Utilization Reviewer 2

Saint Louis, MO

$52K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

Integrated Resources

Care Review Nurse

Columbus, OH · On-site

Insurance Utilization Manager/Review and Millemen Experience (MCG). No case managers if that is their only experience. Must have Utilization Review or Management. Utilization Review (1 year +), Past ...

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How much do insurance utilization reviewer jobs pay per year?

As of Aug 23, 2026, the average yearly pay for insurance utilization reviewer in the United States is $37,992.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,000.00 and $42,000.00 per year, depending on experience, location, and employer.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

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Insurance Utilization Reviewer jobs near you

Utilization Reviewer

Bert Nash Community Mental Health Center

Lawrence, KS • On-site

$65K - $70K/yr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted yesterday

Bert Nash Community Mental Health Center rating

6.2

Company rating: 6.2 out of 10

Based on 8 frontline employees who took The Breakroom Quiz

Job description

Utilization Reviewer
Pay is commensurate with experience within a range of $65,000 to $70,000 annually. Full time, exempt, benefits eligible. Bert Nash offers excellent benefits which include medical, dental, vision, KPERS retirement, life insurance, an Employee Assistance Program (EAP) providing free counseling and resources, and generous PTO.
Caring. Hope. Giving back. Our mission at the Bert Nash Center as the Community Mental Health Center (CMHC) of Douglas County is to advance the health of the community through comprehensive behavioral health services responsive to evolving needs and changing environments. We accomplish this by believing in our team. Each person that works for the Bert Nash Center contributes directly to the success of our clients, organization, and community. Our values of compassion, integrity, equity and hope reflect in everything we do.
The Utilization Reviewer's primary responsibility is to manage and complete monthly clinical record reviews to ensure provision of clinically appropriate care is delivered to clients in the least restrictive but clinically appropriate level as quickly as possible while complying with agency, payers, applicable policies, regulations and accreditation standards. This role's overall goal is to ensure that quality services are provided in the most efficient, cost-effective manner to all eligible clients seeking treatment regardless of the treatment setting or payer.
Responsibilities: The primary responsibility of the Utilization Reviewer is to ensure clinical documentation achieves expected standards, implement and train for consistency in best practices across the organization's facilities, participate and coordinate with teams Quality Improvement Plans or related initiatives. Duties will include but not limited to:
  • Conduct monthly clinical chart reviews to assure clients receive clinically appropriate care and complies with agency, payor, applicable policies, regulations and accreditation standards.
  • Utilize evidence-based calculation to ensure the sample size of charts reviewed provide a high confidence level that results are valid and reliable.
  • Provide chart review results to program directors or managers with both aggregate program data and individual charts needing remediation.
  • Work with directors or program managers on remediation activities to ensure they are completed within 30 days.
  • Meet with teams to help identify and develop continuous quality improvement goal(s) to improve the quality of documentation.
  • Managing organizational risks through implementation and improvement of best practices in clinical documentation, CCBHC regulations, CARF standards and other regulatory requirements.
  • Provide or coordinate the provision of related trainings in collaboration with the Clinical Consultant, Clinical Educator, and other team members.
  • Provides response to clinical quality questions.
  • Champions continuous quality improvement and assists in developing, tracking, and realizing related organizational goals or objectives.
  • Assign, analyze and present the quarterly chart review data for all teams per CARF Standards 2.G. and 2.H.
  • Analyzes monthly chart reviews to identify both areas needing improvement and areas that have improved since previous audits.
  • Maintain and record inventories of chart review occurrences and results.
Qualifications include but not limited to:
  • Licensure in social work, counseling, nursing or psychology.
  • Knowledge and familiarity with electronic health record (EHR) documentation.
  • Three years of experience providing billed services to clients in fields such as nursing, counseling, psychology, therapy, medication management, case management, or other.
  • Master's degree in behavioral health, medical services or administration, nursing, psychology, sociology, or similar.
  • Ability to accurately interpret standards from policies, contracts, and accrediting bodies for implementation.
  • Flexibility in assigned working hours.
  • Ability to negotiate, complete contracted work, analyze operations, and governmental/accrediting body regulations.
  • Interest or experience in quality improvement, quality assurance, or similar background and/or training a plus.
  • Have exemplary existing skills in clinical documentation and familiarity with using EHRs to complete documentation reviews, as well as external tools such as the Microsoft Office Suite.
  • Assist QI team with other duties as needed.

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