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Medical Utilization Review Jobs in California (NOW HIRING)

KPC Health

Utilization Review Tech

Santa Ana, CA · On-site

Utilization Review Technician Under direction of the Utilization Review Technician Supervisor, the ... Ability to interpret and understand various medical insurance plans and make accurate ...

KPC Global MSO

Utilization Review Tech

Santa Ana, CA · On-site

SUMMARY Under direction of the Utilization Review Technician Supervisor, the Utilization Review ... Ability to interpret and understand various medical insurance plans and make accurate ...

OU Health (Parent)

Utilization Review RN

Whittier, CA · On-site

$2.8K/wk

... Specialty Utilization Review Job ID 18027156 Job Title Utilization Review RN Weekly Pay $2800.0 ... ensuring medical necessity, appropriate level of care, and compliance with CMS, EMTALA, and ...

Medix

Utilization Review Nurse

Orange, CA · On-site

$38 - $53/hr

Job Summary Our client is seeking a Utilization Review Nurse responsible for managing the complete ... Communicate confidently and effectively with Medical Directors, physicians, and hospital ...

Sutter Health

Utilization Review Tech III

San Mateo, CA · On-site

$48.91 - $68.47/hr

MPHS-Mills-Peninsula Medical Center Position Overview: Acts independently to perform and coordinate ... Critical thinking skills necessary to provide utilization review/discharge planning services ...

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All JobsMedical Utilization Review JobsMedical Utilization Review Jobs in California

Medical Utilization Review information

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$21

$41

$68

How much do medical utilization review jobs pay per hour?

As of Aug 15, 2026, the average hourly pay for medical utilization review in California is $41.73, according to ZipRecruiter salary data. Most workers in this role earn between $32.98 and $47.93 per hour, depending on experience, location, and employer.

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 medical utilization review a stressful job?

Medical utilization review can be stressful due to the need to evaluate complex medical cases, meet strict deadlines, and ensure accurate decisions. The job often requires attention to detail, critical thinking, and sometimes handling difficult interactions with providers or patients. However, stress levels vary depending on workload, work environment, and individual coping skills.

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.

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 Reimbursement Specialist (CMRS) can enhance job prospects. Relevant skills include attention to detail, analytical thinking, and familiarity with medical records and billing systems.

What does a medical utilization review specialist do in healthcare?

A medical utilization review specialist evaluates healthcare services to determine their necessity, efficiency, and appropriateness based on established guidelines. They review patient records, collaborate with healthcare providers, and ensure compliance with insurance policies, often using specialized software. This role helps control healthcare costs and ensures quality patient care.

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.

What are popular job titles related to Medical Utilization Review jobs in California?

For Medical Utilization Review jobs in California, the most frequently searched job titles are:

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

The top searched job categories for Medical Utilization Review jobs in California are:

What cities in California are hiring for Medical Utilization Review jobs?

Cities in California with the most Medical Utilization Review job openings:

Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in California as of August 2026, with employment types broken down into 1% As Needed, 77% Full Time, 15% Part Time, 2% Temporary, and 5% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $86,795 per year, or $41.7 per hour.

Utilization Review Tech

KPC GLOBAL MEDICAL CENTERS INC.

Santa Ana, CA • On-site

$24.80 - $37.31/hr

Full-time

Posted 21 days ago

Job description

SUMMARY

Under direction of the Utilization Review Technician Supervisor, the Utilization Review Technician coordinates with the Utilization Management Department while being responsible for coordinating phone calls, clinical requests, upkeeps data entry, organizes denials and mailing/faxing appeals, tracking data from various insurance providers and health plans regarding authorization and/or denials, expedite reviews and documentation to insurance providers. Monitors patient charts and records to provide to responsible parties and request for authorization for hospital admission. Reviews treatment plans and status of approvals from insurers. Collects and compiles data as required and according to applicable policies and regulations. Performs administrative duties for the Utilization Management Department, and directed in several aspects of duties. Position is non-RN/LVN.

REQUIREMENTS

  • Ability to establish and maintain effective working relationships across the Health System
  • Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage
  • Follow up with insurance companies regarding the status of outstanding claims and necessary steps for resolution
  • Answer and review pertinent insurance correspondence to ensure complete and accurate reimbursement for medical claims
  • Responsible for working payer correspondence, edits and aged account receivable, and identifying and correcting billing errors
  • Pull daily reports utilizing Microsoft Excel and providing correct correspondence to payer
  • Research payer rules and regulations to maintain current payer knowledge
  • Comply with HIPAA and other compliance requirements to protect patient confidentiality
  • Manage data in internal and external databases with accuracy
  • Provide high-level administrative support and assistance to the Director and Supervisor or other assigned leadership staff
  • Perform clerical and administrative tasks including drafting letters, memos, invoices, reports, and other documents for senior staff
  • Prepare patient charts for medical audits

EDUCATION & EXPERIENCE REQUIREMENTS:

  • High School Diploma
  • Healthcare experience strongly preferred

SKILLS & ABILITIES REQUIREMENTS:

  • Excellent verbal and written communication skills
  • Excellent organizational skills and attention to detail
  • Excellent time management skills with a proven ability to meet deadlines
  • Ability to function well in a high-paced and at times stressful environment
  • Extensive knowledge of office administration, clerical procedures, and recordkeeping systems
  • Able to type minimum of 50 words per minute
  • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
  • ICD-10 and CPT coding experience a plus
  • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
  • Extremely proficient with Microsoft Office Suite or similar software with the ability to learn new or updated software
  • Medical Terminology preferred

PHYSICAL REQUIREMENTS:

  • Body Positions: Sitting and standing for prolonged periods.
  • Body Movements: Arm and hand dexterity.
  • Body Senses: Must have command of close and distant sight, color perception and hearing.
  • Strength: Ability to lift and move up to 25-pounds.

Working Environment:

  • Work in an office, where the climate is controlled.
  • OSHA exposure category: II
  1. Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
  2. Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
  3. Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.
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About KPC Health

Sourced by ZipRecruiter

KPC Health has an integrated approach to serving the people of Riverside, San Bernardino and Orange County. Our acute care medical centers provide high quality, comprehensive and affordable healthcare for the entire family. For us, healthcare is not just about caring for our patients, but also about investing in the people throughout our communities. We are one team with one mission and that mission is for all our patients, and their families to Enjoy Life in Great Health.

Industry

Health care and social assistance

Company size

201 - 500 Employees

Headquarters location

Santa Ana, CA, US

Year founded

2004

Social media

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