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Insurance Utilization Reviewer Jobs in Virginia (NOW HIRING)

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, ...

Carilion Clinic

RN Case Manager

Roanoke, VA · On-site

Collaborates with Utilization Review Nurse. * Maintains regular contact with assigned Utilization ... Aids in the delivery of regulatory letters and patient notices related to insurance coverage/non ...

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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 are Insurance Utilization Reviewers?

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.
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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:
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Insurance Utilization Reviewer jobs near you
Clinical Coordinator - Utilization Review

Clinical Coordinator - Utilization Review

Hampton-Newport News Community Services Board

Hampton, VA

$62K/yr

Full-time

Medical, Dental, Vision, Life, Retirement

Posted 8 days ago

Job description

Clinical Coordinator - Utilization Review

Annual Salary: $62,406

Work Schedule: Monday - Friday 8:30 am - 5:00 pm

The Hampton - Newport News Community Services Board (CSB) is hiring a Clinical Coordinator - Utilization Review for the Region 5 Reinvestment Initiative. This full-time Clinical Coordinator - Utilization Review is responsible for conducting clinical reviews of acute and intermediate care for clinical necessity and appropriateness of care and for managing utilization of beds on a daily basis to ensure movement in a clinically appropriate and expeditious manner. Major duties will include conducting clinical reviews, acute care bed management, and communication of findings and recommendations between hospitals, facilities, and CSB staff. This position will report to the Project Director of the Region 5 Reinvestment Initiative.

ROLE SUMMARY

The Clinical Coordinator (Utilization Review) ensures individuals receive the most appropriate and effective behavioral health services by conducting clinical reviews of acute care and crisis stabilization admissions. Evaluates medical necessity, monitors continued stay criteria, and makes recommendations regarding the most appropriate level of care. Working closely with hospitals, Community Services Board (CSB) staff, and regional partners, coordinates communication, tracks consumer placements, and provides clinical guidance to support informed treatment and placement decisions. Responsibilities include conducting face-to-face assessments, monitoring treatment progress and outcomes, promoting quality and cost-effective care, and preparing regular utilization reports with recommendations for acute, sub-acute, or community-based services. This position plays a critical role in ensuring consumers receive timely, clinically appropriate, and least restrictive treatment options while supporting regional behavioral health initiatives.

To qualify for this position, candidates must have:

  • Master's degree in Human Services.
  • Three (3) years of experience in behavioral health, including utilization management.

BENEFITS

  • Health, Vision, and Dental Insurance
  • Virginia Retirement System
  • Flexible Spending Account (FSA)
  • Life Insurance
  • 11 Paid Holidays

The selected candidate must successfully pass a criminal history fingerprint background investigation, DMV record check, Child Registry search, drug screening test and employment reference checks.

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