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Insurance Utilization Reviewer Jobs in California

CorVel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · On-site

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective ... Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and ...

Corvel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · Remote

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective ... Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and ...

Corvel

CA Utilization Review Nurse I

Rancho Cucamonga, CA · On-site

$30.64 - $45.80/hr

The Utilization Review Nurse gathers demographic and clinical information on prospective ... Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and ...

HCS 247

Travel Utilization Review RN

Apple Valley, CA · On-site

Utilization Review * Discipline: RN * Start Date: ASAP * Duration: 13 weeks * 40 hours per week ... Accident Insurance * Critical Illness Insurance * Disability Insurance * Term Life Insurance

Solomon Page

Travel Utilization Review RN

Hayward, CA · On-site

Utilization Review * Discipline: RN * Start Date: 07/27/2026 * Duration: 13 weeks * 40 hours per ... We offer dental insurance to you and your dependents. * Vision Coverage : Available the 1st of the ...

Solomon Page

Travel Utilization Review RN

Hayward, CA · On-site

Utilization Review * Discipline: RN * Start Date: 08/24/2026 * Duration: 13 weeks * 40 hours per ... We offer dental insurance to you and your dependents. * Vision Coverage : Available the 1st of the ...

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Insurance Utilization Reviewer information

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 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.

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 are Insurance Utilization Reviewers?

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 popular job titles related to Insurance Utilization Reviewer jobs in California? For Insurance Utilization Reviewer jobs in California, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in California look for? The top searched job categories for Insurance Utilization Reviewer jobs in California are:
What cities in California are hiring for Insurance Utilization Reviewer jobs? Cities in California with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you
CA Utilization Review Nurse I

CA Utilization Review Nurse I

CorVel

Rancho Cucamonga, CA • On-site

$30.64 - $45.80/hr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 12 days ago

CorVel rating

7.9

Company rating: 7.9 out of 10

Based on 51 frontline employees who took The Breakroom Quiz

85th of 148 rated financial services

Job description

The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay while supporting the goals of the Case Management department and of CorVel.
This is a remote position.
ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

  • Identifies the necessity of the review process and communicates issues of concern to the appropriate claims staff/customer
  • Collects data and analyzes information to make decisions regarding certification or denial of treatment
  • Documents all work in the appropriate manner
  • Promotes utilization review services with stakeholders
  • Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP)
  • Additional duties as assigned
KNOWLEDGE & SKILLS:
  • Must have thorough knowledge of both CPT and ICD coding
  • Ability to interface with claims staff, attorneys, physicians and their representatives, as well as advisors/clients and coworkers
  • Effective organization skills in a high-volume, fast-paced environment
  • Strong time management skills with the ability to meet designated deadlines
  • Excellent written and verbal communication skills
  • Ability to work both independently and within a team environment
  • Strong interpersonal skills
  • Ability to utilize Microsoft Office including Excel spreadsheets
  • Knowledge of the workers' compensation claims process preferred
  • Knowledge of outpatient utilization review preferred
EDUCATION & EXPERIENCE:
  • Graduate of accredited school of nursing with an associate's degree, Bachelor of Science degree or Bachelor of Science in Nursing
  • Current Nursing licensure in the state of operation required; RN is required unless local state regulations permit LVN/LPN
  • 4 or more years of recent clinical experience
  • Prospective, concurrent, and retrospective utilization review experience preferred
  • Experience in the clinical areas of OR, ICU, CCU, ER and/or orthopedics preferred

PAY RANGE:
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.
For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.
Pay Range: $30.64 - $45.80 per hour
A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management
In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.
ABOUT CORVEL:
CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
#LI-Remote
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

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