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Insurance Utilization Reviewer Jobs in Providence, RI

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Reviewer II, Medical

Carolina, RI · On-site +1

Provides support and review of medical claims and utilization practices. Description Logistic ... Life insurance * Paid Time Off (PTO) * Nine paid holidays * On-site cafeterias and fitness centers ...

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Insurance Utilization Reviewer information

See Providence, RI salary details

$31.3K

$38.4K

$44.5K

How much do insurance utilization reviewer jobs pay per year?

As of Aug 31, 2026, the average yearly pay for insurance utilization reviewer in Providence, RI is $38,381.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,300.00 and $42,400.00 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 Providence, RI?

For Insurance Utilization Reviewer jobs in Providence, RI, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in Providence, RI look for?

The top searched job categories for Insurance Utilization Reviewer jobs in Providence, RI are:

Insurance Utilization Reviewer jobs near you

LPN - Utilization Review Nurse

High Point Treatment Center

New Bedford, MA • On-site

$32 - $39/hr

Other

Medical, Dental, Vision, Retirement

Re-posted 12 days ago

High Point Treatment Center rating

5.7

Company rating: 5.7 out of 10

Based on 12 frontline employees who took The Breakroom Quiz

Job description

LPN - Utilization Review Nurse
Program & Location: Central Utilization Review Department - New Bedford, MA
Qualifications: Graduate of an Accredited Professional School or Nursing or; master's degree in social work, clinical psychology/counseling or mental health preferred with experience in substance use and/or mental health services.
Pay Range: $32 - $39 per hour (experience, education & licensure dependent)
Status: Full Time, 40hrs/week
Shift: Monday-Friday 7:30am-4:00pm
On-Site in New Bedford, MA
About Us
High Point & Affiliated Organizations is a health and human service agency whose mission is to treat and prevent substance use disorders and mental illness. High Point has programs located throughout Southeastern Massachusetts offering a full continuum of care for substance use and mental health treatment, including inpatient, outpatient, residential, and community-based services. Programs and services also assist survivors of abuse, violence, and families experiencing homelessness. High Point believes that everyone has inherent goodness, worth, and dignity. Our goal is to help individuals and families achieve personal change and improve their quality of life.
UR Nurse Requirements:
  • Proficiency with computers, Microsoft Word, email, typing, and other basic office technology.
  • Knowledge of ASAM criteria;
  • Managed care and utilization management experience;
  • Able to organize and structure own workload, attention to detail, and ability to maintain up to date tracking and filing systems;
  • Good clinical judgment, understanding of medical necessity and evidence-based practices;
  • Understanding of boundaries and ethics;
  • Possesses a pleasant telephone manner and customer service skills;
  • Good verbal and written communication skills;
  • The ability to work collaboratively with others in a collaborative and cooperative manner;
  • Understands the diseases of psychiatry and addictions and treatment modalities;
  • Presents professional at all times and allows for flexibility;
  • Problem solving abilities;
  • Critical thinking skills;
  • TB screening;
  • Certification in HPAO De-escalation training;
  • Knowledge of computer programs including Microsoft Office and Electronic Medical Records.
UR Nurse Duties and Responsibilities:
  • Maintains and submits any current Licensure or Certificate necessary for the performance of the position.
  • Compliance with Federal Regulations, 42 CFR Part II, Confidentiality of Alcohol and Drug Abuse Patients and HIPPA
  • Utilization management of all patients, ensuring proper authorization is obtained for all insured inpatient services;
  • Clinical reviews with insurance companies for continued stay, step downs to lower level of care and step ups to higher level of care (except IPU);
  • Responsible for assuring that the business office receives accurate billing information in a timely manner;
  • Keep counselors / nurses of insured patients updated as to their status;
  • Attend daily multi-disciplinary treatment team meetings;
  • Obtain necessary clinical, medical, and treatment information from clinical and medical staff to provide a comprehensive concurrent review;
  • Review all new admissions daily, verifying insurance eligibility, level of care, and obtaining all applicable authorizations;
  • Complete, discharge summary information to insurance companies when applicable;
  • Assist with admission approvals as needed;
  • Attend mandatory meetings and trainings;
  • Attend monthly departmental meetings;
  • Responsible for continued education in the field of substance abuse, nursing and related courses, when necessary;
  • Coordinate and support the initiation and completion of all appeal processes as necessary for insurance claim denials and/or retrospective reviews;
  • Provide assistance and support on the unit when necessary;
  • Utilizes standard precautions at all times;
  • Demonstrates behaviors that recognize the rights of patients as defined by the patient rights;
  • Other duties as assigned by the supervisor.
Benefits:
  • Medical Insurance
  • Dental Insurance
  • Vision Insurance
  • Long & short term disability
  • Discounted auto/home and renters insurance
  • 403b - Retirement
  • FSA & DSA
  • PMLA
  • Employee Assistance Program
  • Bonuses & Referral
  • Eligibility for free classes to become a Licensed Counselor or Recovery Coach
  • Education days to use towards CEU's
  • Free meals at select programs and when available
  • Unmatched Leave Time (FT employees can earn up to 3 weeks in first year)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

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