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Insurance Utilization Reviewer Jobs in Virginia (NOW HIRING)

Sentara Healthcare

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site +1

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Insurance • 401k/403B with Employer Match • Tuition Assistance - 5,250/year and discounted ...

Sentara Health Plans

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site

$65 - $85/hr

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Pet Insurance * Legal Resources Plan Colleagues have the opportunity to earn an annual ...

New

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

Life Insurance * Flexible Spending or Health Savings Account * Generous Paid Time Off * Career ... party reviewer's level of care decisions and expectations to appropriate clinical and ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

$26 - $35/hr

... party reviewer's level of care decisions and expectations to appropriate clinical and ... Life Insurance * Flexible Spending or Health Savings Account * Generous Paid Time Off * Career ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

Life Insurance * Flexible Spending or Health Savings Account * Generous Paid Time Off * Career ... party reviewer's level of care decisions and expectations to appropriate clinical and ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA · On-site

Life Insurance * Flexible Spending or Health Savings Account * Generous Paid Time Off * Career ... party reviewer's level of care decisions and expectations to appropriate clinical and ...

UHS

UTILIZATION REVIEW COORDINATOR

Danville, VA

Life Insurance * Flexible Spending or Health Savings Account * Generous Paid Time Off * Career ... party reviewer's level of care decisions and expectations to appropriate clinical and ...

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

$60 - $80/hr

... reviews using the established hospital criteria. Communicates effectively with insurance companies ... utilization management. · Appeals all denials ensuring accuracy of information and effective ...

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

... reviews using the established hospital criteria. Communicates effectively with insurance companies ... utilization management. • Appeals all denials ensuring accuracy of information and effective ...

Summit BHC

Utilization Specialist - Acute

Williamsburg, VA · On-site

$24 - $28/hr

... reviews using the established hospital criteria. Communicates effectively with insurance companies ... utilization management. • Appeals all denials ensuring accuracy of information and effective ...

UHS

Director of Utilization Management

Danville, VA · On-site

$79K - $95K/yr

... insurance offering, a physician network and various related services located all over the U.S ... Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, ...

UHS

Director of Utilization Management

Danville, VA · On-site

... insurance offering, a physician network and various related services located all over the U.S ... Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, ...

UHS

Director of Utilization Management

Danville, VA · On-site

... insurance offering, a physician network and various related services located all over the U.S ... Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, ...

UHS

Director of Utilization Management

Danville, VA · On-site

... insurance offering, a physician network and various related services located all over the U.S ... Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, ...

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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 Virginia?

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

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

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

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

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

Insurance Utilization Reviewer jobs near you

UTILIZATION REVIEW NURSE

Sentara Healthcare

Norfolk, VA • On-site, Remote

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 9 days ago

Sentara Health rating

6.8

Company rating: 6.8 out of 10

Based on 417 frontline employees who took The Breakroom Quiz

498th of 898 rated healthcare providers

Job description

City/State
Norfolk, VA
Work Shift
First (Days)
Overview:
Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse.
The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conducts pre-certification, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Responsible for written and/or verbal notification to members and providers. Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Education:
• BSN (preferred)
Certification:
• Registered Nurse (required)
Experience:
• 3 years of acute care clinical experience (required)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Keywords: Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQA
Benefits: Caring For Your Family and Your Career
• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to 10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance - 5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down - 10,000
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission "to improve health every day," this is a tobacco-free environment.
For positions that are available as remote work, Sentara Health employs associates in the following states:
Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

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