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Insurance Utilization Reviewer Jobs in Idaho (NOW HIRING)

Aldridge Pite LLP

Title Reviewer

Meridian, ID · On-site

Aldridge Pite, LLP is a multi-state law firm that focuses heavily on the utilization of technology ... Company Paid Life and Disability Insurance plans * Medical, Dental and Vision Plans with ...

New

Evolent

Physician Reviewer-Radiology (Part Time)

Boise, ID · On-site

$95 - $100/hr

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a ... insurance benefits) to qualifying employees. All compensation determinations are based on the ...

Telligen

Peer Review Psychiatrist

Boise, ID · On-site

Comfort with electronic health records (EHRs) and utilization review software * Familiarity with state and federal guidelines, HIPAA compliance, and insurance or Medicaid-specific medical necessity ...

New

Trinity Health

Clinical Resource Manager

Boise, ID · On-site

$61K - $85K/yr

Provides hospital case management/utilization review and discharge planning collaboratively ... Experience in case management, home health, and/or the insurance industry preferred. WHAT YOU WILL ...

Evolent

Field Medical Director, Vascular Surgeon

Boise, ID · On-site

$130 - $140/hr

... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... insurance benefits) to qualifying employees. All compensation determinations are based on the ...

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All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Idaho

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 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 popular job titles related to Insurance Utilization Reviewer jobs in Idaho?

For Insurance Utilization Reviewer jobs in Idaho, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in Idaho look for?

The top searched job categories for Insurance Utilization Reviewer jobs in Idaho are:

What cities in Idaho are hiring for Insurance Utilization Reviewer jobs?

Cities in Idaho with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you
Infographic showing various Insurance Utilization Reviewer job openings in Idaho as of August 2026, with employment types broken down into 2% As Needed, 87% Full Time, 7% Part Time, 2% Temporary, and 2% Contract. Highlights an 91% In-person, and 9% Remote job distribution.

Medicaid Utilization Review Analyst - MED

LUMA

Coeur D Alene, ID • On-site

$27.12 - $27.70/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 22 days ago

Job description

DEDICATED TO STRENGTHENING THE HEALTH, SAFETY, AND INDEPENDENCE OF IDAHOANS
THIS ANNOUNCEMENT WILL BE OPEN UNTIL FILLED. APPLICANTS ARE ENCOURAGED TO APPLY AS SOON AS POSSIBLE TO BE CONSIDERED.
Do you have an interest in making a difference for Idaho's vulnerable population by helping to ensure Medicaid dollars are spent on services they need? Do you have strong analytical and critical thinking skills? Then this job may be for you. This position is instrumental in protecting the integrity of the Medicaid program. By joining our team, you will have the opportunity to help identify and deter fraud, waste and abuse in the Medicaid program. As an analyst, you will play a crucial role in conducting preliminary investigations by reviewing claims data and medical records, reviewing provider billing practices, conducting provider and participant interviews, and ensuring that Medicaid services are billed and paid in accordance with Medicaid rules and regulations. This position will communicate findings and provide program education to Medicaid providers through written and oral communication, recovering identified overpayments, assessing civil monetary penalties and taking other administrative actions when warranted. This position is located in Coeur d' Alene.
This position may be eligible for limited telework after successful completion of probation and necessary training. Approval to telecommute is not guaranteed and subject to termination at any time.
The successful applicant will be required to complete a criminal history background investigation. Employment is dependent upon satisfactory results of the investigation.
BENEFITS:
The State of Idaho offers a robust total compensation and benefits package, including but not limited to:
  • We have one of the Nation's best state retirement systems (PERSI) that offers a lifetime benefit at retirement.
  • 11 paid holidays
  • Paid sick and vacation that begins accruing on your first day of employment; can be used immediately after accruing (no waiting time)
  • Paid parental leave
  • Medical, vision, and dental insurance benefits that become effective first of the month following your hire date. All contributions can be pre-tax (full-time/30+ hours per week)
  • 2 voluntary supplemental retirement plans including both pre-tax and Roth options
  • Deferred compensation plan
  • Life insurance for self, spouse, and children
  • Short and long-term disability insurance
  • Flexible Spending Accounts (FSA)
  • Wide variety of training opportunities
  • Some positions offer flexible hours and/or telecommuting
  • Additional perks and discounts available through medical provider
  • Public Service Loan Forgiveness (PSLF) Eligibility
  • Employee assistance program

Additional information related to benefits and/or State programs can be found here: https://dhr.idaho.gov/StateEmployees/Benefits.html.*
EXAMPLE OF DUTIES:
  • Analyzes claims data and reports to identify Medicaid provider and participant utilization patterns that may indicate program abuse.
  • Reviews claims data, medical records and rules and regulations to ensure services were billed appropriately and in accordance with rules and regulations.
  • Conducts participant and provider telephone and in-person interviews to gather information on which to base decisions.
  • Conducts on-site reviews at provider locations, documenting evidence and findings.
  • Meets by phone or in-person with Medicaid providers to discuss findings.
  • Write reports and send notices of findings that are clear, concise and legally defensible.
  • Recommends and participates in implementation of policies and procedures for monitoring program utilization.
  • Confers with professional medical consultants concerning appropriateness and quality of medical goods and services provided to Medicaid participants.
  • Uses analytical and critical thinking skills and professional judgment in determining if providers are in compliance with Medicaid rules and regulations.

MINIMUM QUALIFICATIONS:
You must possess all the minimum qualifications below to pass the exam for this position. Please make sure your resume or work history supports your meeting the minimum qualifications for this position. Failure to do this may disqualify you from being considered for this position. It is highly recommended to attach a one-page cover letter to your application to demonstrate how you meet the requirements below.
  • Good knowledge of medical terminology, medical diagnostic and procedural terms, common medical payment procedural codes used in Current Procedural Terminology Fourth Edition (CPT-4), and other nationally recognized coding references. Typically gained by completion of college level courses covering items A-C above or a seminar or training for CPT-4/ICD OR at least one year of work experience using the above resources.
  • Good knowledge of data processing systems as used in program monitoring and management information processes. Typically gained by completion of coursework/training regarding data processing systems and their use OR at least six months of work experience working with the above type data processing systems.
  • Experience recognizing patterns of medical assistance billing that suggest fraud, abuse, over-utilization, child abuse, and claims processing problems. Typically gained by at least six months of work experience in a medical or insurance office with responsibility for reviewing or processing claims that included recognizing problems such as: patterns of abuse; fraud; incomplete information; improper coding etc.
  • Experience compiling, analyzing, and interpreting statistical data, and developing recommendations. Typically gained by successful completion of coursework and/or training covering statistics AND at least six months of work experience that required both verbal and written communications of findings to both internal and external entities.
  • Experience conducting interviews to obtain facts for cases. Typically gained by at least six months of work experience conducting interviews for investigations to solicit facts, record information, and determine eligibility or an appropriate course of action based on findings. Types of qualifying experience could include a background in credit collection, law enforcement, financial institutions, or social service programs or services. Experience as an office/administrative support staff conducting informal day-to-day interviews is not in-depth enough to qualify. Experience conducting employment interviews is typically non-qualifying. Experience being interviewed, e.g. to obtain employment, does not qualify.
  • Experience preparing recommendations and writing interview/investigative reports. Typically gained by at least six months experience preparing recommendations and writing interview/investigative reports.

Below is preferred experience. It is not required for the position but applicants with this experience may receive consideration over other applicants.
  • Some knowledge of in-depth interviewing techniques and procedures. Typically gained through college coursework or workshop/seminar that discussed interviewing techniques and procedures in detail and was the focus of the coursework or workshop/seminar.
  • Experience working in Medicaid programs with demonstrated knowledge of Medicaid regulations and administrative requirements. Typically gained by working at least one year for a state Medicaid agency or working for a Medicaid provider in a position that required Medicaid knowledge.

Learn About a Career with DHW
If relocating to Idaho, the Department of Health & Welfare does not reimburse the cost of relocating and the department does not sponsor anyone with a work visa.
PLEASE NOTE: application assistance is not available after the business hours listed below, on the weekends, or on holidays and you must apply before 11:59 pm on the closing date. When applying, use CHROME as your browser to avoid complications.
If you have questions, please contact us at:
Email is the quickest way to get an answer to your questions.
(answered Monday through Friday during business hours MST)
EMAIL: dhwjobs@dhw.idaho.gov
PHONE:(208) 334-0681
EEO/ADA/Veteran:
The State of Idaho is committed to providing equal employment opportunities and prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, political affiliation or belief, sex, national origin, genetics, or any other status protected under applicable federal, state, or local laws.
The State of Idaho is committed to access and reasonable accommodations for individuals with disabilities, auxiliary aids and services are available upon request. If you require an accommodation at any step in our recruitment process, you are encouraged to contact (208) 334-2263 (TTY/TTD: 711), or email ada.coordinator@dhr.idaho.gov.
Preference may be given to veterans who qualify under state and federal laws and regulations.
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About Luma

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Industry

Arts, entertainment, and recreation

Company size

201 - 500 Employees

Headquarters location

Santa Monica, CA, US

Year founded

2002

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