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Insurance Utilization Reviewer Jobs in Massachusetts

MiraVista

Utilization Review Clinician

Holyoke, MA · On-site

As a Utilization Review Clinician for MiraVista in Holyoke, Massachusetts, you'll bring your ... Employer paid life and AD&D Insurance * Generous Paid Time Off * Flexible Spending Account

US Tech Solutions

Utilization Review Nurse

Canton, MA · On-site

$55 - $60/hr

Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience. * Strong knowledge of: * Utilization Management (UM) * Medical Necessity Review * Prior Authorization

Lifepoint Health

Specialist, Utilization Review

Holyoke, MA · On-site

$33.22 - $44.85/hr

Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued ... UR contacts external case managers/managed care organizations for certification of insurance ...

Acadia Healthcare

Utilization Specialist

Haverhill, MA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...

Beth Israel Lahey Health

Utilization Nurse

Plymouth, MA · On-site

$37.14 - $82.22/hr

Reviews admission data to establish the appropriate level of care using Interqual criteria ... Knowledge of government and insurance company reimbursement policies in regards to admission ...

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Insurance Utilization Reviewer information

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.

What are popular job titles related to Insurance Utilization Reviewer jobs in Massachusetts?

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

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

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

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

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

Insurance Utilization Reviewer jobs near you

Utilization Review Clinician

Holyoke, MA • On-site

MiraVista
Health Care and Social Assistance • 1 - 10 employees
Learn more about MiraVistaexternal

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 11 days ago

Job description

Join us as a Utilization Review Clinician!

Schedule: Monday - Friday, 40 hours, onsite 5 days a week.

As a Utilization Review Clinician for MiraVista in Holyoke, Massachusetts, you’ll bring your experience and knowledge where your voice matters. A Utilization Review Clinician is an integral part of our multidisciplinary team.

As a Utilization Review Clinician:

  • You will be an active participant in the health care team.

  • You are responsible for pre-certification, concurrent and discharge reviews, appeals and denials, and the compliance of contracted quality measures identified by managed care organizations.

  • You will serve as liaison between the hospital and outside payor sources in accordance with the mission and core principals of MiraVista Behavioral Health Center.

The Utilization Review Clinician will have the following:

  • Master's level clinician or RN.

  • Previous utilization management, preferably in an inpatient psychiatric setting

  • License eligible (LMHC or LICSW preferred) or RN

  • Possess sufficient knowledge regarding clinical treatment of psychiatric patients, the mental health care delivery system, and the managed care environment

  • Display excellent communication skills and an ability to integrate clinical and financial information in the context of an overall utilization management program

  • Requires the ability to work in a multidisciplinary, fast paced environment with a demonstrated sense of autonomy and professionalism.

When you join the growing MiraVista team as a Utilization Review Clinician, you’ll receive:

  • Medical, Dental, and Vision

  • 401(k) match

  • Employer paid long term disability (LTD)

  • Short term disability (STD)

  • Employer paid life and AD&D Insurance

  • Generous Paid Time Off

  • Flexible Spending Account

  • Tuition Reimbursement

Pay Range:

Compensation will be determined based on the candidate's relevant experience.

$80,000 - $90,000

MiraVista is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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