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Insurance Utilization Reviewer Jobs (NOW HIRING)

Dane Street, LLC

PRN Utilization Review Nurse Reviewer

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their ...

Dane Street

PRN Utilization Review Nurse Reviewer

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their ...

Banyan

Utilization Review Specialist

Pompano Beach, FL · On-site

$50K - $65K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Verify insurance benefits, coordinate authorizations, and communicate effectively with external case managers and managed care organizations * Establish and maintain contracts with managed care ...

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Insurance Utilization Reviewer information

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How much do insurance utilization reviewer jobs pay per year?

As of Aug 13, 2026, the average yearly pay for insurance utilization reviewer in the United States is $37,992.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,000.00 and $42,000.00 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.
More about Insurance Utilization Reviewer jobs
What cities are hiring for Insurance Utilization Reviewer jobs? Cities with the most Insurance Utilization Reviewer job openings:
What states have the most Insurance Utilization Reviewer jobs? States with the most job openings for Insurance Utilization Reviewer jobs include:
What job categories do people searching Insurance Utilization Reviewer jobs look for? The top searched job categories for Insurance Utilization Reviewer jobs are:
Insurance Utilization Reviewer jobs near you

Utilization Review Nurse

Maniilaq Association

Kotzebue, AK • On-site

Other

Posted 9 days ago

Job description

Maniilaq Association is a P.L. 93-638 Native/Indian Preference/EEO Employer
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Utilization Review Nurse Job Code: 2026:OTZ-201 Location: Kotzebue, Alaska Program: Nursing Division FT/PT Status: Full Time Job Responsibilities:
MANIILAQ ASSOCIATION
5/2026
Title: Utilization Management Nurse Pay Grade: 31
Program: Nursing Status: Exempt
Housing Priority: 3 Covered: Yes
POSITION SUMMARY
The Utilization Management Nurse (UMN) is responsible for performing Utilization Review and managing risk, coordinates and facilitates with departmental staff on Durable Medical Equipment (DME), and pharmacy prior authorizations. THE UMN works with the medical treatment and case management team in the coordination of patient care including the development of new operational changes and new services to ensure compliance and risk mitigation. The UMN will use a process that includes screening and case finding, comprehensive multidimensional assessment, connection with available resources, implementation of the plan and ongoing monitoring and re-assessment/follow-up. The UMN assists with the Quality and Case Management programs and, coordinates the IPC4 program. This position reports directly to the Chief Nursing Officer or designee.
PRINCIPAL DUTIES AND RESPONSIBILITIES
  1. Coordinates the IPC4 process in Medicare/Medicaid and private insurances.
  2. Assists in revenue procurement by:making sure insurance approvals are completed correctly with no penalty; helping to identify alternate resources of funding such as VA, Denali Kid Care, Medicare, and Medicaid; and monitoring the appeal process when claims are denied.
  3. Chairs Quarterly Utilization Review Committee meetings to improve utilization of resources and improve patient care.
  4. Submits Quarterly reports to CMO and CNO for Board of Director meetings.
  5. Works closely with Coders and Billers to insure accurate, timely billing information.
  6. Completes Utilization Review processes as assigned.
  7. Oversees development and maintenance of a resource database of Federal, State, community, and institutional resources.
  8. Assists in arranging team conferences and networks for relationship building and resource development with village leaders, Community Health Aides/Practitioners, MHC Medical Staff, MHC Nursing Staff, private insurance contacts, Medicaid/Medicare contacts, ANMC Providers, and the CM/SC/UR Team.
  9. Participates on improvement projects as assigned.
  10. Participates in Medicaid Task Force committee through Alaska Native Health Board.
  11. Completes Quality Improvement, Quality Assurance and Performance Improvement projects and tasks as assigned.
  12. Utilizes team building, problem solving skills and lean principles in the on-going quality improvement initiatives.
  13. Identify, assess, and monitor potential clinical, operational, and compliance risks within the Utilization Review and Case Management programs.
  14. Report and document incidents, near-misses, and adverse events in accordance with organizational policy and regulatory standards.
  15. Participate in root cause analyses and collaborate with leadership to implement corrective action plans to mitigate future risks.
  16. Collaborate with the Risk Management team to review, update, and communicate policies and procedures relevant to utilization review and patient care coordination.
  17. Educate clinical and administrative staff on risk awareness, safety protocols, and compliance requirements.
  18. Coordinate and facilitate prior authorizations for DME by collaborating with patients, clinical staff and providers to ensure clients' needs are met.
  19. Collaborate with providers and pharmacist process prior authorizations for specialized high-cost medications; monitor appeal process if claims are denied.
Job Qualifications:
MINIMUM REQUIREMENTS
Current licensure as a RN with at least two years of Case Management, Utilization Review, Discharge Planning or Quality Improvement experience preferred. Knowledge of acute and chronic illnesses, specialty clinic procedures, and community health nursing. Must be able to pass the core competencies assigned to this position and maintain the educational requirements of the program. Ability to utilize various computer programs, including Cerner and Microsoft Office. Demonstrates a wide theory base in order to interact in an effective manner with physicians, health team members, community agencies, and clients/families with diverse opinions, values, and religious and cultural ideals. Ability to work autonomously with little direction and be directly accountable for practice. Knowledge of and experience working with all regulatory, state, and federal agencies.
Other Job Information (if applicable):
DISCLAIMER
The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be considered an exhaustive list of all responsibilities, duties and skills required of personnel in this job, and the employer reserves the right to revise or change this description. This description does not constitute a written or implied contract of employment. To perform this job successfully, an individual must be able to satisfactorily perform each of the above essential duties and meet physical demands. Reasonable accommodations may be made to enable individuals with disabilities to meet those conditions.

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