ZipRecruiter

Log In

1

Insurance Utilization Reviewer Jobs in Crofton, MD

ICONMA

Spec, Utilization Management

Baltimore, MD · On-site

... Insurance company, is looking for a Spec, Utilization Management for their Remote location. Responsibilities: * Utilizing key principles of utilization management, the Utilization Review Specialist ...

Summit BHC

Utilization Assistant - Acute

Annapolis, MD · On-site

Assists in utilization reviews and insurance appeals. Responds to inquiries from patients, their families, and professional referral sources. Roles and Responsibilities: • Assists the admissions ...

Comagine Health

Clinical Reviewer DC

Washington, DC · On-site

The Clinical Reviewer position supports utilization management activities by assessing the medical ... Medical, dental and vision insurance * Paid time off for vacation, illness and volunteering

Summit BHC

Utilization Assistant - Acute

Annapolis, MD · On-site

Assists in utilization reviews and insurance appeals. Responds to inquiries from patients, their families, and professional referral sources. Roles and Responsibilities: • Assists the admissions ...

New

previous pagenext page

Showing results 21-40

All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Crofton, MD

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 Aug 15, 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 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 Crofton, MD?

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

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 Management Specialist

System One

Baltimore, MD • Remote

Contractor

Medical, Dental, Vision, Life, Retirement

Re-posted 23 days ago

Job description

Utilization Management Specialist (UM / Utilization Review Nurse) — Remote

Location: 100% Remote (U.S.) — Maryland compact/eligibility required Type: Contract (approx. 3 months; potential extension) Schedule: Mon–Fri, 8:00am–5:00pm ET (1-hour lunch) - Flex after ramp-up start time between 7:00am–9:00am ET Pay (W2): USD 51.00/H

Job overview

In this role, you’ll use your clinical background and utilization management experience to review requests for care and determine medical necessity, appropriateness, and benefit coverage. You’ll work fully remote and leverage MCG, medical policy, and regulatory guidelines while collaborating with Medical Directors and internal teams to support timely, accurate authorization decisions.

What you’ll do

  • Perform prospective, concurrent, and retrospective utilization reviews (medical + behavioral health).
  • Make medical necessity / appropriateness determinations and support prior authorizations.
  • Use clinical criteria and policy resources daily (including MCG / Milliman Care Guidelines).
  • Review clinical documentation, benefits, and mandates to ensure services align with coverage and guidelines.
  • Research diagnoses/treatments and high-cost services; summarize findings and escalate complex cases to Medical Directors as needed.
  • Collaborate with internal partners and providers to support benefit application and appropriate levels/settings of care.
  • Maintain accurate documentation and protect PHI while managing a busy caseload.

Required qualifications

  • Active RN or LPN license (RN preferred) — Maryland compact/eligibility required
  • 5+ years clinical nursing experience
  • 2+ years care management / utilization management experience
  • MCG experience (required)
  • Experience supporting Commercial/FEP/Medicare lines of business and applying medical policy/regulatory standards
  • Strong critical thinking, written communication, and ability to work independently in a remote setting
  • Comfortable with web-based tools + Microsoft Office (Word/Excel/PowerPoint)
  • Guiding Care and FACETS (required)

Nice to have

  • Critical Care or ER clinical background
  • Experience with LCD/NCD, Medicare guidelines, ASAM, or other authorization criteria sets

System One, and its subsidiaries including Joulé and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.

System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.

#M-1 #LI-AJ1 Ref: #851-Rockville-S1