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Medical Utilization Review Jobs (NOW HIRING)

Albany Medical College

$77 - $119/hr

## Utilization Review NurseApplylocations: 43 New Scotland Avenue Albany, NY 12208time type: Full ... Albany Med Health System is an equal opportunity employer.This role may require access to ...

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MiraVista

Utilization Review Clinician

Holyoke, MA · On-site

As a Utilization Review Clinician for MiraVista in Holyoke, Massachusetts, you'll bring your ... Medical, Dental, and Vision * 401(k) match * Employer paid long term disability (LTD) * Short term ...

Acrisure, LLC

Utilization Review Nurse

Bradenton, FL · On-site

$55 - $90/hr

## Utilization Review NurseApplyremote type: Hybridlocations: 1301 6th Ave W - BRADENTON, FLposted on ... This role reviews medical information submitted by treating providers, determines whether treatment ...

Acrisure

Utilization Review Nurse

Bradenton, FL · On-site

This role reviews medical information submitted by treating providers, determines whether treatment ... Experience in utilization review or case management is highly beneficial, particularly within ...

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Medical Utilization Review information

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$42

$68

How much do medical utilization review jobs pay per hour?

As of Sep 4, 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.

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.

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 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.

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.

How do I get into a medical utilization review?

To become a medical utilization review specialist, candidates typically need a healthcare background such as nursing, medical assisting, or health administration, along with knowledge of insurance policies and medical coding. Certification programs like the Certified Professional Medical Auditor (CPMA) or Certified Medical Reviewer (CMR) can enhance job prospects. Relevant skills include attention to detail, analytical thinking, and familiarity with medical records and billing systems.

Is medical utilization review a good job?

Medical utilization review is a healthcare role focused on evaluating the necessity and efficiency of medical services, often requiring knowledge of insurance policies and clinical guidelines. It offers opportunities for stable employment, typically involves administrative and analytical skills, and may require certification such as the Certified Professional Medical Auditor (CPMA). The job can provide a predictable schedule and work-from-home options, making it a viable career choice for those interested in healthcare administration.
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What states have the most Medical Utilization Review jobs?

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What job categories do people searching Medical Utilization Review jobs look for?

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Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 15% Part Time, and 6% Contract. Highlights an 92% Physical, 1% Hybrid, and 7% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review

Discovery Institute of Addictive Disorders Inc.

Marlboro, NJ • On-site

Full-time

Re-posted 10 days ago

Key responsibilities

  • Obtain initial and concurrent insurance authorizations for all levels of care.

  • Review clinical documentation to ensure it supports medical necessity and submit required information to insurance companies within specified timeframes.

  • Monitor authorization expiration dates, communicate decisions to clinical staff, and prepare and submit appeals for denied services.

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.