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Medical Utilization Review Jobs (NOW HIRING)

Uniti Med

Travel Utilization Review

Tewksbury, MA · On-site

Uniti Med is seeking a travel Utilization Review for a travel job in Tewksbury, Massachusetts. & Requirements * Specialty: Utilization Review * Discipline: Therapy * Start Date: 08/10/2026 * Duration ...

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How much do medical utilization review jobs pay per hour?

As of Jul 24, 2026, the average hourly pay for medical utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

Is being a MOA a good entry level job?

Medical Office Assistants (MOAs) often serve as entry-level healthcare support roles, requiring basic administrative and clinical skills. The position can provide valuable experience in medical settings and may lead to advancement with additional training or certifications. However, job responsibilities and requirements vary by employer and location.

What jobs pay 4000 a week without a degree?

Medical Utilization Review roles typically require relevant healthcare knowledge and certifications but may not always require a degree. High-paying jobs that can reach $4,000 a week without a degree include sales positions, real estate brokers, commercial pilots, and certain skilled trades like electricians or plumbers with experience. These roles often depend on experience, performance, or licensing rather than formal education.

What are the key skills and qualifications needed to thrive as a Medical Utilization Review Specialist, and why are they important?

To thrive as a Medical Utilization Review Specialist, you need a background in healthcare (often as an RN or LPN), strong analytical abilities, and in-depth knowledge of medical terminology and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and certifications such as Certified Professional in Healthcare Quality (CPHQ) are commonly required. Excellent communication, critical thinking, and attention to detail are vital soft skills for effectively reviewing cases and collaborating with providers. These competencies ensure accurate, efficient decision-making that supports both patient care standards and cost-effective healthcare delivery.

Is utilization review a stressful job?

Medical utilization review can be stressful due to the need for accuracy, meeting strict deadlines, and managing complex cases. The role often requires attention to detail, critical thinking, and sometimes working under pressure, but stress levels vary depending on workload and work environment.

What qualifications do you need to be a utilization review nurse?

A utilization review nurse typically needs a registered nurse (RN) license, which requires completing an accredited nursing program and passing the NCLEX-RN exam. Relevant experience in case management, insurance, or clinical settings, along with knowledge of healthcare regulations and utilization review processes, is also important. Certification in case management or utilization review, such as the Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), can enhance job prospects.

What are some common challenges faced by professionals in Medical Utilization Review, and how can they be addressed?

Professionals in Medical Utilization Review often encounter challenges such as managing high caseloads, staying updated with changing healthcare regulations, and balancing the needs of patients with cost-containment measures. Effective time management and ongoing education in current medical guidelines can help address these issues. Additionally, strong communication skills are essential for collaborating with healthcare providers and insurance companies to ensure appropriate care decisions while maintaining compliance.

What is the difference between Medical Utilization Review vs Medical Claims Reviewer?

AspectMedical Utilization ReviewMedical Claims Reviewer
CredentialsCertifications like CCM, RHIA, or RHIT often preferredCertifications such as CPC or CCS beneficial
Work EnvironmentHealthcare facilities, insurance companies, or third-party review organizationsInsurance companies, healthcare payers, or claims processing centers
Primary FocusAssessing necessity and appropriateness of medical servicesReviewing and processing insurance claims for payment
Industry UsageCommonly used in healthcare and insurance sectorsPrimarily in insurance and healthcare billing sectors

Medical Utilization Review focuses on evaluating the necessity of medical services, while Medical Claims Review centers on processing insurance claims. Both roles require healthcare knowledge and certifications, but they serve different functions within the healthcare and insurance industries.

What is medical utilization review?

Medical utilization review is a process used by healthcare organizations and insurance companies to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. The goal is to ensure that patients receive necessary care while avoiding unnecessary or redundant treatments. Utilization review helps control healthcare costs and maintains quality standards by reviewing cases before, during, and after care is provided. The process typically involves nurses, physicians, and other healthcare professionals who assess clinical information to make recommendations or decisions about coverage.
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What cities are hiring for Medical Utilization Review jobs? Cities with the most Medical Utilization Review job openings:
What states have the most Medical Utilization Review jobs? States with the most job openings for Medical Utilization Review jobs include:
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Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in the United States as of July 2026, with employment types broken down into 1% As Needed, 78% Full Time, 14% Part Time, and 7% Contract. Highlights an 97% Physical, 1% Hybrid, and 2% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review

Discovery Institute NJ

Marlboro, NJ • On-site

Full-time

Posted yesterday

Job description

Position Summary
The Utilization Review (UR) Specialist is responsible for obtaining and maintaining insurance authorizations for clients receiving substance use disorder treatment services. This position works closely with clinical staff, admissions, and insurance companies to ensure medical necessity documentation is accurate, authorizations are obtained timely, and reimbursement is maximized while maintaining compliance with payer requirements, Medicaid regulations, and accreditation standards.
Essential Duties and Responsibilities
  • Obtain initial and concurrent insurance authorizations for all levels of care.
  • Review clinical documentation to ensure it supports medical necessity.
  • Submit clinical information to insurance companies within required timeframes.
  • Monitor authorization expiration dates and request extensions before expiration.
  • Communicate authorization decisions and payer requirements to clinical staff.
  • Track approved days and notify leadership of denials or reductions in care.
  • Prepare and submit appeals for denied services when appropriate.
  • Maintain accurate authorization records in the electronic health record (EHR).
  • Work collaboratively with Admissions, Clinical, Nursing, and Billing departments.
  • Verify insurance benefits and coverage when necessary.
  • Monitor payer portals for authorization updates.
  • Assist with Medicaid and managed care authorization processes.
  • Participate in utilization review meetings and case conferences.
  • Generate reports on authorization status, denials, appeals, and payer trends.
  • Ensure compliance with Joint Commission, state, federal, and payer regulations.
  • Maintain confidentiality in accordance with HIPAA regulations.
  • Perform other duties as assigned.
Qualifications
  • High school diploma required; Associate's or Bachelor's degree preferred.
  • Minimum of two years of utilization review, case management, medical billing, or behavioral healthcare experience preferred.
  • Experience in substance use disorder or behavioral health treatment strongly preferred.
  • Knowledge of ASAM Criteria preferred.
  • Familiarity with Medicaid, commercial insurance, and managed care plans.
  • Strong organizational and time management skills.
  • Excellent verbal and written communication skills.
  • Ability to prioritize multiple cases in a fast-paced environment.
  • Proficient in Microsoft Office and electronic health record systems.
Knowledge, Skills, and Abilities
  • Understanding of insurance authorization processes.
  • Knowledge of medical necessity criteria and documentation standards.
  • Strong analytical and critical thinking skills.
  • Excellent customer service and professional communication.
  • Ability to work independently while collaborating with interdisciplinary teams.
  • Attention to detail and accuracy.
  • Ability to maintain confidentiality.
Performance Expectations
  • Maintain timely insurance authorizations with minimal lapses.
  • Reduce avoidable authorization denials.
  • Ensure documentation meets payer standards.
  • Maintain accurate records and reporting.
  • Demonstrate professionalism, teamwork, and excellent customer service.
  • Comply with all organizational policies, HIPAA, Joint Commission standards, and applicable federal and New Jersey regulations.

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