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Insurance Utilization Reviewer Jobs in Crofton, MD

MedStar Health

RN Team Lead Utilization Review

Clinton, MD · On-site

$89K - $162K/yr

About the Job In-patient Utilization Review RN experience highly preferred. Candidate must live in ... Identifies insurance information obtains authorization communicates with financial counseling and ...

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Insurance Utilization Reviewer information

See Crofton, MD salary details

$31.4K

$38.4K

$44.5K

How much do insurance utilization reviewer jobs pay per year?

As of Jul 20, 2026, the average yearly pay for insurance utilization reviewer in Crofton, MD is $38,422.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,400.00 and $42,500.00 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 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.
What job categories do people searching Insurance Utilization Reviewer jobs in Crofton, MD look for? The top searched job categories for Insurance Utilization Reviewer jobs in Crofton, MD are:
What cities near Crofton, MD are hiring for Insurance Utilization Reviewer jobs? Cities near Crofton, MD with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you
Utilization Review RN (Remote)

Utilization Review RN (Remote)

Amergis Healthcare Staffing

Baltimore, MD

Full-time

Medical, Dental, Vision, Life, Retirement

Posted 4 days ago

Job description

"

The Utilization Review Specialist is responsible for the assessment and review of the healthcare delivery system with a concentration on tasks that promote cost-effective quality care and cost containment in accordance with various federal and/or state statutes, regulations and guidelines as well as facility policy.

Essential Duties and Responsibilities:

  • Performs utilization review in accordance with all state mandated regulations
  • Analyzes insurance, governmental and accrediting standards to determine criteria concerning admissions, treatment, and length of stay
  • Assures compliance with state and federal regulations and billing requirements
  • Maintains compliance with regulation changes affecting utilization management
  • Reviews patient records and evaluates patient progress
  • Ensures high standard of patient care by establishing best practice benchmarks
  • Obtains and reviews necessary medical reports and related treatment plan to conduct review
  • Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients
  • Ensures appropriate and cost-effective healthcare services to patients.
  • Analyzes patient records and participates in interdisciplinary collaboration with professional staff
  • Facilitates educational programs as directed to keep physicians and professional staff informed about regulations affecting utilization management
  • Recognizes and reports appropriately cases of fraud, abuse or incorrect utilization
  • Consults with Social Services Department regarding the level of nursing care and collaborates with other departments in evaluation of projects affecting discharge plans
  • Supports performance improvement programs
  • Performs continuing review on medical records and identifies and evaluates need of ongoing hospitalization and services

Minimum Requirements:

  • Current license for the state in which the nurse practices if nursing licensure is required by contract
  • A Bachelor’s Degree in Nursing or at least two years’ experience in Utilization Review preferred
  • Certification in Utilization Review or Utilization Management preferred
  • Experience with Microsoft Office Suite and the ability to learn new information systems and software programs
  • Strong problem solving, project management and organizational skills with an ability to work in a fast paced environment
  • General knowledge of managed care delivery system
  • Complies with all relevant professional standards of practice 
  • Participation and completion of Amergis' Competency program when applicable
  • Current CPR if applicable
  • TB questionnaire, PPD or chest x-ray if applicable 
  • Current Health certificate (per contract or state regulation) 
  • Must meet all federal, state and local requirements 
  • Successful completion of new hire training as applicable to job site 
  • Understand patient confidentiality and HIPAA requirements  
  • Ability to effectively elicit/provide information to and from appropriate individuals (including, but not limited to, supervisors, co-workers, clients) via strong communication skills; proficiency in the English language is required  
  • Computer proficiency required 
  • Must be at least 18 years of age 
"
Benefits
At Amergis, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
  • Competitive pay & weekly paychecks
  • Health, dental, vision, and life insurance
  • 401(k) savings plan
  • Awards and recognition programs 
*Benefit eligibility is dependent on employment status. 

About Amergis
Amergis, formerly known as Maxim Healthcare Staffing, has served our clients and communities by connecting people to the work that matters since 1988. We provide meaningful opportunities to our extensive network of healthcare and school-based professionals, ready to work in any hospital, government facility, or school. Through partnership and innovation, Amergis creates unmatched staffing experiences to deliver the best workforce solutions.  

Amergis is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.

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