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Insurance Utilization Reviewer Jobs in Crofton, MD

Comagine

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

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

ICONMA

Spec, Utilization Management

Baltimore, MD · On-site

Spec, Utilization Management Our client, a Health Insurance company, is looking for a Spec ... Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will ...

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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 Sep 8, 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 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 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 Coordinator

System One

Baltimore, MD • Remote

Contractor

Medical, Dental, Vision, Life, Retirement

Re-posted 2 days ago

Job description

UTILIZATION MANAGEMENT COORDINATOR

Location: Remote — client site in Baltimore, MD (21224) Type: Contract (3 months to start; expected extension possible) Schedule: 40 hours/week — must include a weekend day Pay (W2): USD 24.70/H

JOB OVERVIEW

In this role, you’ll support Utilization Management (UM) clinical teams by handling non-clinical administrative work tied to pre-service authorization, utilization review support, care coordination workflows, and quality-of-care processes. You’ll help manage authorization intake, documentation, and provider/member support—while working in a fast-paced environment where schedule flexibility (including weekends) is required.

WHAT YOU’LL DO

  • Provide member/provider administrative support such as benefit verification, authorization creation/management, claims inquiries, and case documentation.

  • Review incoming authorization requests for initial determination and/or triage items for clinical review and resolution.

  • Support day-to-day coordination for the department, including answering/responding to phone calls, taking messages, and responding to basic inquiries.

  • Research information and assist with issue resolution and operational problem-solving.

  • Assist with reporting, data tracking, and organizing/disseminating information (including Continuity of Care processes and tracking Peer-to-Peer reviews).

REQUIRED QUALIFICATIONS

  • High School Diploma (or equivalent)

  • 3+ years of experience in healthcare claims/service areas and/or healthcare office/administrative support

  • Ability to work effectively within a multidisciplinary team (internal and external partners)

  • Strong communication, organization, and customer service skills

  • Strong attention to detail with sound judgment and decision-making

  • Comfortable with web-based tools and Microsoft Office (Word, Excel, PowerPoint)

NICE TO HAVE

  • Knowledge of CPT and ICD-10 coding / medical terminology used in managed care

  • Experience in a managed care environment (health plan / UM support)

  • Phone-heavy/customer support experience

  • Experience with Medicaid/Medicare (government programs)

  • Exposure to tools such as Facets, Guiding Care, and/or NICE CXone

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-M2 #LI-

Ref: #851-Rockville-S1

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About System One

Sourced by ZipRecruiter

System One helps employers get work done more efficiently and economically without compromising quality. Over our 35+ year history, we've helped connect thousands of talented people with innovative companies. The excitement of a perfect fit motivates us every single day.

Industry

Business consulting services and recruiting and staffing services

Company size

5,001 - 10,000 Employees

Headquarters location

Pittsburgh, PA, US

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