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Insurance Utilization Reviewer Jobs in Rhode Island

Ourhrconnect

Reviewer II, Medical

Carolina, RI · On-site +1

Provides support and review of medical claims and utilization practices. Description Logistic ... Life insurance * Paid Time Off (PTO) * Nine paid holidays * On-site cafeterias and fitness centers ...

New

Ourhrconnect

Reviewer II, Medical

Carolina, RI · On-site +1

Provides support and review of medical claims and utilization practices. Description Logistic ... Life insurance * Paid Time Off (PTO) * Nine paid holidays * On-site cafeterias and fitness centers ...

New

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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 Rhode Island?

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

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

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

What cities in Rhode Island are hiring for Insurance Utilization Reviewer jobs?

Cities in Rhode Island with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you

Behavioral Health Intake and Utilization Review Coordinator

CharterCARE of Rhode Island

Providence, RI

Full-time

Re-posted 12 days ago

Job description

Summary: The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating admissions, and overseeing utilization review activities to ensure timely access to care and appropriate resource utilization. This role is actively involved with communicating with other community hospitals and Emergency Departments and will also facilitate outside admissions to our services to maximize hospital census. This role ensures adherence to regulatory and payer requirements while serving as a key liaison between patients, providers, and insurance carriers. 

Education: Bachelor’s degree Nursing required. Master’s degree preferred. 

Experience: Minimum 2–3 years of experience in behavioral health, preferably in intake or utilization review roles. 

License:  RI RN License required. 

Skills and Qualifications: 

  • Strong clinical assessment and diagnostic skills. 

  • Working knowledge of behavioral health levels of care and medical necessity criteria (e.g., MCG, InterQual). 

  • Familiarity with insurance authorization processes and managed care systems. 

  • Excellent organizational, communication, and interpersonal skills. 

  • Proficiency in EHR and Microsoft Office Suite. 

Working Conditions, Physical Environment and/or Safety Requirements: Lifting up to 30 lbs. and occasionally lifting and/or carrying such articles as files, books, etc. Involves sitting, walking, stooping, and reaching. However, as necessary, must be able to meet the physical requirements for staff level positions in the department(s).  

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