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Medical Utilization Review Jobs in Florida (NOW HIRING)

GQR Healthcare

Travel Utilization Review RN

Fort Myers, FL · On-site

$1.7K - $1.8K/wk

Utilization Review * Discipline: RN * Start Date: 09/28/2026 * Duration: 14 weeks * 40 hours per ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

Enlyte

Utilization Reviewer 2

Tampa, FL · On-site

$59K - $76K/yr

Minimum of 2 years of utilization review experience; or an advanced degree without experience. * Knowledge of medical terminology, treatment modalities, and healthcare guidelines. * Analytical and ...

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Medical Utilization Review information

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$15

$31

$51

How much do medical utilization review jobs pay per hour?

As of Sep 5, 2026, the average hourly pay for medical utilization review in Florida is $31.60, according to ZipRecruiter salary data. Most workers in this role earn between $24.95 and $36.30 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.

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

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

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

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

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

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

Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in Florida as of August 2026, with employment types broken down into 94% Full Time, and 6% Part Time. Highlights an 88% In-person, and 12% Remote job distribution, with an average salary of $65,722 per year, or $31.6 per hour.

Senior Utilization Review Specialist - Part Time

Sage Clinical RCM, LLC

Gulfport, FL • On-site

Part-time

Posted 14 days ago

Job description

Description: Position Summary

The Part Time Senior Utilization Review Specialist is an experienced registered nurse responsible for concurrent and retrospective review of hospital services to support appropriate utilization, accurate patient status, timely payer authorization, and medical necessity compliance. This senior individual-contributor role serves as a clinical resource for complex cases and partners with physicians, care management, patient access, coding, and revenue cycle teams to reduce avoidable denials and support appropriate reimbursement.

Key Responsibilities

• Perform concurrent and retrospective utilization review for assigned inpatient, observation, and outpatient cases using approved criteria, payer policies, and clinical judgment.

• Apply InterQual, MCG, or client-approved criteria to support medical necessity, level of care, continued stay, and patient-status determinations.

• Obtain, submit, and track payer notifications and authorizations; communicate clinically relevant information to payer medical-management teams within required time frames.

• Identify potential medical-necessity, authorization, status, and documentation risks early and escalate appropriately to prevent avoidable denials.

• Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle partners to clarify documentation and support appropriate care progression.

• Coordinate clinical information and deadlines for peer-to-peer review or denial escalation when needed; maintain complete, accurate documentation in the designated systems.

• Serves as a member of the Utilization Review Committee-prepares reports to include utilization trends, denial patterns, extended stays, and workflow barriers; communicate actionable findings to leadership.

• Performs escalations to UR Committee members to ensure that compliance with regulations for patient status changes by providers are occurring per policy. Documents escalations and presents outcomes to UR committee.

• Serve as a senior clinical resource, providing guidance and support on complex review questions while adhering to established policies and escalation pathways.

• Participate in quality audits, education, process improvement, and other initiatives that strengthen utilization management performance.

Requirements: Required Qualifications

• Current, unrestricted RN license.

• Five or more years of acute-care hospital experience, including at least three years in utilization review, utilization management, case management, or a closely related function.

• Demonstrated experience applying medical-necessity and level-of-care criteria, including concurrent review and continued-stay review.

• Working knowledge of inpatient versus observation status, payer authorization requirements, Medicare and managed-care utilization principles, and denial-prevention practices.

• Strong clinical judgment, prioritization, documentation, communication, and collaborative problem-solving skills.

• Ability to independently manage a high-volume, deadline-driven caseload while exercising sound judgment regarding escalation.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN).

• Certification in case management or utilization management, such as CCM or ACM.

• Experience with InterQual, MCG, Cerner, or comparable utilization-management and electronic health-record systems.

• Experience supporting hospital denials management, peer-to-peer coordination, or care-progression initiatives.


Role Boundaries and Work Expectations

• This is a senior individual-contributor role and does not include direct people management unless separately assigned.

• The specialist follows St. John's Health clinical policies, payer requirements, and established Sage Clinical RCM workflows.

• The role requires discretion with protected health information and strict compliance with HIPAA, client security standards, and applicable regulations.

• Availability during agreed hospital business hours and participation in required meetings, education, and workflow updates are expected.