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Insurance Utilization Reviewer Jobs in Maryland (NOW HIRING)

Prime Time Healthcare

Utilization Review

Baltimore, MD · On-site

Now Hiring: RN Utilization Review - Baltimore, MD Are you a passionate RN professional looking for ... Medical, vision & dental insurance * 401(k) matching program * Flexible schedules * Travel ...

Summit BHC

Assigns all clients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements. Ensures ...

MedStar Health

RN Utilization Review

Clinton, MD · On-site

$89K - $162K/yr

About the Job **Must be local to the DC/MD region with acute Utilization Review RN experience ... Management insurance UR or related experience preferred Licenses and Certifications * RN - ...

MedStar Health

RN Team Lead Utilization Review

Clinton, MD · On-site

$89K - $162K/yr

About the Job Candidate must have acute care Utilization Review experience. Candidate must live in ... Identifies insurance information obtains authorization communicates with financial counseling and ...

Summit BHC

Utilization Specialist - Addiction Recovery | Anabranch Recovery Center | Terre Haute, Indiana ... reviews using the established hospital criteria. Communicates effectively with insurance companies ...

ICONMA

Spec, Utilization Management

Baltimore, MD · On-site

... Insurance company, is looking for a Spec, Utilization Management for their Remote location. Responsibilities: * Utilizing key principles of utilization management, the Utilization Review Specialist ...

Luminis Health

Utilization Management Nurse

Annapolis, MD · On-site

$34 - $55/hr

Reviews the medical record by applying utilization review criteria, to assess clinical, financial ... Pay Range $34-$55 USD Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance ...

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All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Maryland

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 Maryland? For Insurance Utilization Reviewer jobs in Maryland, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Maryland look for? The top searched job categories for Insurance Utilization Reviewer jobs in Maryland are:
What cities in Maryland are hiring for Insurance Utilization Reviewer jobs? Cities in Maryland with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you
Infographic showing various Insurance Utilization Reviewer job openings in Maryland as of August 2026, with employment types broken down into 90% Full Time, 6% Part Time, and 4% Contract. Highlights an 89% In-person, 2% Hybrid, and 9% Remote job distribution.

Physician Consultant

The Copper River Family of Companies

Baltimore, MD • On-site

Other

Posted 17 days ago

Job description

Copper River Strategies is seeking a Physician Consultant to provide clinical expertise and medical oversight in support of healthcare insurance operations. The Physician Consultant will resolve complex medical record issues, interpret clinical documentation, support intake, coding, quality assurance, and appeals activities. This position requires an actively practicing, board-certified physician with experience in health insurance, utilization review, or claims and a strong understanding of Medicare program requirements and clinical guideline interpretation.

This position is primarily remote; however, onsite presence at the Center for Medicare & Medicaid Services (CMS) in Baltimore, Maryland, may be required on an as-needed basis to support program requirements, stakeholder meetings, and other business needs.

  • Responsibilities (include but are not limited to): 
    • Provide clinical expertise in the review and interpretation of complex medical records.
    • Resolve complex clinical documentation and medical record issues.
    • Interpret clinical documentation in accordance with applicable medical guidelines and program requirements.
    • Support intake and clinical review processes.
    • Provide clinical guidance supporting coding accuracy and consistency.
    • Support quality assurance activities and clinical quality reviews.
    • Assist with the review and resolution of medical appeals.
    • Apply clinical judgment to complex cases requiring physician-level expertise.
    • Interpret Medicare program requirements and applicable clinical guidelines.
    • Collaborate with clinical, operational, coding, quality assurance, and appeals teams.
    • Provide recommendations regarding complex medical and clinical issues.
    • Support continuous improvement of clinical review and healthcare insurance processes.

Essential Job Qualifications and Requirements:

  • Education and License:
    • Board certified for a minimum of three (3) years in an American Board of Medical Specialties (ABMS)-recognized specialty
    • Medical degree from an accredited medical school required
    • Active, valid, unrestricted U.S. medical license required
  • Required Experience:
    • Actively practicing physician with a minimum of three (3) years of clinical practice experience
    • Experience in health insurance, utilization review, or claims
  • Demonstrated Knowledge & Skills:
    • Knowledge of the Medicare program
    • Demonstrated ability to interpret and apply clinical guidelines
    • Strong analytical, clinical judgment, and communication skills
    • Clinical evaluation and medical record interpretation
    • Clinical documentation interpretation
    • Coding review and clinical coding support
    • Quality assurance and clinical quality review
    • Appeals and complex case resolution
    • Medicare program requirements
    • Interpretation and application of clinical guidelines

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