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Insurance Utilization Reviewer Jobs in Boise, ID

Evolent

Field Medical Director, Vascular Surgeon

Boise, ID · On-site

$130 - $140/hr

... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... insurance benefits) to qualifying employees. All compensation determinations are based on the ...

Turning Winds

Be Seen First

Behavioral Health Billing Manager (Adolescent Treatment Center)

Boise, ID · Remote

$75K - $100K/yr

Utilization Review (UR) Leadership: Schedule and manage the UR process, including preparing ... with insurance medical directors. Qualifications & Skills * Experience: 5+ years in behavioral ...

EleMental Health

Office Manager

Boise, ID · On-site

Collect demographic, insurance, and required intake information. * Ensure all consent forms ... Review rejected claims and facilitate corrections. * Reconcile daily payments and deposits ...

EleMental Health

Office Manager

Boise, ID

Collect demographic, insurance, and required intake information. * Ensure all consent forms ... Review rejected claims and facilitate corrections. * Reconcile daily payments and deposits ...

Corvel

Medical Case Manager I

Boise, ID · On-site

$62K - $93K/yr

A cost containment background, such as utilization review or managed care is helpful. * Strong ... Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. In addition ...

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All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Boise, ID

Insurance Utilization Reviewer information

See Boise, ID salary details

$29.5K

$36.2K

$41.9K

How much do insurance utilization reviewer jobs pay per year?

As of Aug 13, 2026, the average yearly pay for insurance utilization reviewer in Boise, ID is $36,159.00, according to ZipRecruiter salary data. Most workers in this role earn between $32,400.00 and $40,000.00 per year, depending on experience, location, and employer.

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 Boise, ID? For Insurance Utilization Reviewer jobs in Boise, ID, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Boise, ID look for? The top searched job categories for Insurance Utilization Reviewer jobs in Boise, ID are:
Insurance Utilization Reviewer jobs near you

Clinical Resource Manager Case Manager

Trinity Health

Boise, ID • On-site

Part-time

Re-posted 4 days ago

Trinity Health rating

6.6

Company rating: 6.6 out of 10

Based on 354 frontline employees who took The Breakroom Quiz

569th of 887 rated healthcare providers

Job description

Employment Type:
Part timeShift:
Day Shift
Description:
CLINICAL RESOURCE MANAGER / CASE MANAGER
Part-time, Friday, Saturday, Sunday and Monday, E/O Week
Boise Regional Medical Center
SUMMARY:
Provides hospital case management/utilization review and discharge planning collaboratively determining level of care needs beyond acute care, providing decision support to patients/families and physicians, managing patient and family expectations, and ensuring a smooth transition to the next level of care and services. Coordinates the integration of social services into patient care as appropriate. Coordinates the hospital activities concerned with case management/utilization review and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies and procedures. Ensures quality patient care and adheres to regulatory compliance. Provides concurrent assistance and support to physicians and other clinical members of the health care team in coordinating the delivery of services for a select group of patients. To help achieve quality clinical and cost outcomes, incorporates real-time contacts with physicians, nursing, and ancillary care givers to establish specific treatment, cost, and transition targets and to facilitate transition planning.
REQUIREMENTS:
  • Colleague must have an RN license, as defined by their primary work state (Idaho or Oregon)

  • IDAHO ONLY: If a nurse moves to Idaho from another compact state, they must apply for licensure by endorsement and update their primary state of residence to Idaho within 60 days of being hired.

  • All colleagues must provide licensure or proof of application for secondary state within 90 days of hire.

  • BSN required. A master's degree is preferred.

  • A minimum of 2 years of varied hospital clinical experience is required.

  • Experience in case management, home health, and/or the insurance industry preferred.

WHAT YOU WILL DO:
  • Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.

  • Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, Geriatric as applicable).

  • Revenue Management: ensures the accuracy of documenting services and supplies provided to the patients.

  • Coordinates the integration of social services/case management functions into patient care, discharge, and home planning process with other hospital departments, external service organizations, agencies and healthcare facilities.

  • Completes a screening/assessment of physician assigned cases to determine medical necessity/status determinations and transition needs. Reassesses, monitors, and modifies transition needs as appropriate.

  • Conducts concurrent medical record review using established medical necessity criteria to determine correct level of care for acute patients. Assists physicians with completing transfer and discharge orders. Maintains knowledge of federal, state, and private agency review requirements and regulations.

  • Provides education to all health care team members including physicians regarding requirements to meet regulatory standards.

  • Promotes effective and efficient utilization of clinical resources from admission to discharge.

  • Initiates and presents "denial letters" as appropriate. Completes PASRRs for admission to skilled nursing facilities. Delivers Condition Code 44 letters to patients and educates them on Medicare benefits.

  • Researches and locates resources for patients for example: assistance in competing medication applications for financial assistance through pharmaceutical companies, works closely with our Patient Financial Advocates in the Medicaid pending process, and works closely with outside facilities to obtain equipment in situations when patients have limited funding available to them.

  • Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, cases, and desired patient outcomes.

  • Introduces self to patient and family and explains clinical resource manager role and the process for patient and family to contact clinical resource manager.

  • Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions.

  • Participates in multidisciplinary patient care rounds and/or conferences as appropriate to review treatment goals, optimize resource utilization, provides family education and identification of post-hospital needs.

  • Utilizes physician advisor referral as appropriate.

  • Adheres to department established process in reviewing 30 day re-admissions.

  • Follows established patient choice policy.

  • Documents assessment of primary and back up plans along with communications to patient, family and care team.

  • Documents interventions taken to meet the needs of their individual patients in Power Chart.

  • Actively participates in department staff meetings and department sub teams.

  • Ensures discharge planning compliance with Medicare Conditions of Participation/regulations and Joint Commission standards.

Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health.
Visit www.saintalphonsus.org/careers to learn more about the benefits, culture and career development opportunities available to you at Saint Alphonsus Health System.
Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

What Trinity Health employees say

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About Trinity Health

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Trinity Health Ann Arbor is a 537 -bed teaching hospital located on 340 acre campus. Recognized by IBM Watson as a Top 100 Hospital and #1 Teaching Hospital, Trinity Health Ann Arbor has been a leading health care provider for more than 100 years. Trinity Health has received numerous local and national awards in recognition of our leadership, quality outcomes, and clinical excellence.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Livonia, MI, US

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