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Insurance Utilization Reviewer Jobs in Pasadena, TX

HealthCare Support

Utilization Management

Houston, TX · On-site

$38 - $42/hr

Microsoft Office (Word, Outlook, Excel) Benefits for RN Outpatient Utilization Review Remote Texas: * Health Insurance * Dental Insurance * Life Insurance * Employee Assistance Program (EAP) * Access ...

Actalent

Utilization Review Nurse

Houston, TX · On-site

$30 - $40/hr

Job Title: RN Clinical Review Nurse (Utilization Review Nurse) The Clinical Review Clinician for ... Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term ...

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All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Pasadena, TX

Insurance Utilization Reviewer information

See Pasadena, TX salary details

$28.3K

$34.7K

$40.2K

How much do insurance utilization reviewer jobs pay per year?

As of Aug 28, 2026, the average yearly pay for insurance utilization reviewer in Pasadena, TX is $34,714.00, according to ZipRecruiter salary data. Most workers in this role earn between $31,100.00 and $38,400.00 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 are popular job titles related to Insurance Utilization Reviewer jobs in Pasadena, TX?

For Insurance Utilization Reviewer jobs in Pasadena, TX, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in Pasadena, TX look for?

The top searched job categories for Insurance Utilization Reviewer jobs in Pasadena, TX are:

What cities near Pasadena, TX are hiring for Insurance Utilization Reviewer jobs?

Cities near Pasadena, TX with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you

Remote UTILIZATION REVIEW NURSE - RN

Houston, TX • On-site

Nexus Health Systems
Health Care and Social Assistance • 501 - 1,000 employees

6.3

Company rating: 6.3 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Respectful managers

Learn more about Nexus Health Systemsexternal

Other

Medical, Dental, Vision, Retirement, PTO

Posted 20 days ago

Job description

Remote Utilization Review Registered Nurse (UR RN)

Nexus Health Systems is seeking an experienced Utilization Review Registered Nurse (UR RN) to join our growing Utilization Management team. This fully remote position plays a critical role in ensuring patients receive medically necessary, high-quality care while promoting appropriate resource utilization and regulatory compliance.

If you're a detail-oriented RN with experience in utilization review, case management, or behavioral health and enjoy collaborating with interdisciplinary teams to improve patient outcomes, we'd love to hear from you.

What You'll Do
  • Conduct concurrent and retrospective utilization reviews to determine medical necessity and appropriate level of care.
  • Apply evidence-based criteria, including InterQual (or similar), to support clinical decision-making and payer compliance.
  • Collaborate with physicians, case managers, and interdisciplinary teams to facilitate timely authorizations, discharge planning, and appropriate transitions of care.
  • Review clinical documentation to ensure accuracy, completeness, and compliance with payer and regulatory requirements.
  • Manage insurance authorizations, denials, appeals, and level-of-care determinations.
  • Monitor utilization trends and contribute to quality improvement initiatives that enhance patient outcomes and operational efficiency.
  • Participate in multidisciplinary utilization review meetings and provide recommendations to optimize care delivery.
  • Maintain accurate documentation within the electronic health record (EHR) while ensuring HIPAA compliance.
Qualifications

Required

  • Associate Degree in Nursing (ADN) from an accredited nursing program.
  • Current, unrestricted Texas RN license or Compact RN license.
  • Minimum of 2 years of acute care clinical nursing experience.
  • At least 3 years of Utilization Review or Case Management experience involving complex medical/surgical and/or behavioral health patients.
  • Strong knowledge of payer guidelines, medical necessity criteria, and utilization management principles.
  • Excellent critical thinking, communication, and organizational skills.
  • Proficiency with electronic health records (EHRs) and Microsoft Office applications.

Preferred

  • Bachelor of Science in Nursing (BSN).
  • Experience with InterQual or MCG criteria.
  • Behavioral health utilization review experience.
  • Experience with Meditech.
  • Professional certifications such as CCM, CPHQ, or HCQM.
Why Nexus Health Systems?

At Nexus Health Systems, our mission is to improve lives through compassionate, high-quality care. As a member of our Utilization Review team, you'll collaborate with dedicated healthcare professionals while helping ensure patients receive the right care at the right time.

We offer:

  • Competitive compensation
  • Comprehensive medical, dental, and vision benefits
  • Paid time off and company holidays
  • 401(k) with company match
  • Professional development and continuing education opportunities
  • A collaborative, mission-driven culture
  • Fully remote work environment

If you're ready to make a meaningful impact in healthcare while enjoying the flexibility of working remotely, we'd love to hear from you.

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