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Insurance Utilization Reviewer Jobs in Georgia (NOW HIRING)

Clarvida - Georgia

Utilization Manager

Columbus, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Augusta, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Columbus, GA · On-site

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Savannah, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Augusta, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Columbus, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Savannah, GA · On-site

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida

Utilization Manager

Columbus, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida

Utilization Manager

Savannah, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Savannah, GA · On-site

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida

Utilization Manager

Augusta, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Savannah, GA

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

Clarvida - Georgia

Utilization Manager

Augusta, GA · On-site

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Pet Insurance * DailyPay- daily access to your earnings without waiting for payday! * SoFi at Work ...

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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 Georgia? For Insurance Utilization Reviewer jobs in Georgia, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Georgia look for? The top searched job categories for Insurance Utilization Reviewer jobs in Georgia are:
What cities in Georgia are hiring for Insurance Utilization Reviewer jobs? Cities in Georgia with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you

D107 - C&A MH Crisis - Utilization Management Coordinator

riveredge

Macon, GA

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 19 days ago

Job description

Utilization Management Coordinator

 

Company Overview:

At River Edge Behavioral Health in Macon, GA, employees are expected to develop meaningful relationships with patients, establishing trust and making a difference in the lives of clients and their families. We believe in supporting our team as well as our clients with our comprehensive benefits package and a supportive work culture, including health, dental, and vision benefits, paid vacation, retirement plans, and more.

Position Overview:

The Utilization Management Coordinator role is focused on ensuring clients receive the appropriate level of behavioral health care while maintaining compliance with medical necessity, authorization, and documentation requirements. The position combines utilization review, care coordination, insurance authorization management, and administrative oversight within behavioral health services.

 

Location/Schedule:

3575 Fulton Mill Road, Macon, GA – 36 hour – 3–12-hour shifts between Sunday-Saturday 7am-7pm or 7pm-7am.

 

Key Responsibilities

  • Create Connects batch files 
  • Retrieve and process response files from Beacon’s SFTP site 
  • Work Connects documents in rejected, denied, hold, no CID, multi-final payer and status appropriately 
  • Review discharge connects and flip to UM complete 
  • Manage and process BHL CSU authorizations and update Carelogic 
  • Review and process AC file for BHL CSU authorization 
  • Complete State Discharge process for Fulton locations 
  • Create PTRF referral via Beacon authorization request 
  • Review and process Connects documents in UM review 

Qualifications

  • High School Diploma (Bachelors in helping profession such as social work, community counseling, counseling psychology, or criminology preferred) 
  • 1-3 years of utilization management experience 

Additional Benefits:

  • Flexible spending accounts
  • 11 Paid holidays
  • Voluntary Life Insurance

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