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Medical Utilization Review Jobs in Nebraska (NOW HIRING)

CHI Health

Utilization Review RN

Omaha, NE · On-site

$33.51 - $48.58/hr

Job Summary and Responsibilities As our Utilization Review RN, you will play a pivotal role in optimizing healthcare delivery by ensuring medical necessity and appropriate patient status throughout ...

Bryan Health

Utilization Management RN Lead

Lincoln, NE · On-site

Performs duties as a Utilization Management RN by determining the medical necessity of requests by performing first level reviews and using approved evidence-based guidelines/criteria. 8. Takes UM-RN ...

Ourhrconnect

Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization. * Conducts research into new or controversial medical procedures ...

Ourhrconnect

Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization. * Conducts research into new or controversial medical procedures ...

Son

Medicaid Review Nurse - Central Office

Lincoln, NE · On-site

$40/hr

Experience with utilization review, CQI processes, or peer review practices. * Experience using electronic health record, tracing systems, or medical claims databases. * Experience reviewing ...

Ourhrconnect

$309K - $413K/yr

Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization. * Conducts research into new or controversial medical procedures ...

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Medical Utilization Review information

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 Nebraska?

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

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

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

Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in Nebraska as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 17% Part Time, and 6% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution.

Utilization Review Specialist

Berkshire Hathaway Homestate Companies

Omaha, NE • On-site

Full-time

Re-posted 3 days ago

Job description

Berkshire Hathaway Homestate Companies, Workers Compensation Division, has an opening for a Utilization Review Specialist in Omaha to join its Medical Management team.  The individual ensures that medical treatment requests from providers are medically appropriate and reviewed in compliance with State laws and Company policies. 
ESSENTIAL RESPONSIBILITIES
  • Triages and manages intake coordination of requests for authorization and independent medical review requests. 
  • Reviews authorization requests for approval in accordance with evidence-based medical treatment guidelines. 
  • Researches claim files in relation to the requested medical treatment, interprets medical reports while utilizing critical thinking, and applies appropriate established guidelines to requested treatment. 
  • Advocates for the injured worker and Claims department, ensuring proposed treatment requests are appropriate for the diagnosis. 
  • Escalates treatment requests outside of authorization authority for review by a Utilization Review Specialist 2 or Utilization Review Nurse. 
  • Ensures that utilization review processes are performed in accordance with the time limits and other requirements set by State law and Company policy. 
  • Routinely contacts providers to clarify treatment requests and examination findings, as well as to obtain additional medical information as needed. 
  • Gains and Maintains a thorough understanding of Company policies regarding the review of authorization requests by Utilization Review Specialists. 
  • Establishes and maintains a close, positive communicative relationship and working partnership with Medical Bill Review staff to ensure effective and efficient integrated medical management of treatment provided to injured workers.
  • Fosters a positive and close working relationship with other Company staff, including adjusting staff, other Medical Management staff, Special Investigations Unit, Legal, Liens, Customer Care, and Client Services.
  • Maintains patient confidentiality and safeguards protected health information in accordance with State and Federal laws and Company policies. 
  • Enters clear, concise, and accurate documentation of requested medical treatments, to include clinical findings, treatment guidelines, and determinations. 
  • Ensures that appropriate notices are forwarded to medical providers, injured workers, Claims staff, and attorneys. 
  • Provides general office or administrative support throughout the department.  
QUALIFICATIONS
  • EDUCATION: Bachelor's or Associate's degree in a medical field from an accredited college or technical school required. 
  • EXPERIENCE: Minimum of 6 months of relevant experience and/or training in a medical field, or equivalent combination of education and experience, required. 
  • TECHNICAL SKILLS: Able to effectively use Microsoft Office/365 applications and able to become proficient in proprietary and vendor software applications. 
  • LANGUAGE ABILITY: Able to read and understand basic documents, including statutes, regulations, medical records, medical bills, medical resource materials, claim notes, and claim data fields. Able to write clear, concise reports accurately conveying complex and nuanced information, as well as correspondence on medical and legal points. Able to effectively present information and respond to questions with adjusting staff, Management, and others. 
  • MATH AND REASONING ABILITY: Able to solve practical problems and deal with a variety of variables in situations where only limited standardization exists. Able to interpret a variety of instructions furnished in written, oral, diagram, graph, or schedule form. Able to apply concepts such as addition, subtraction, multiplication, division, fractions, percentages, ratios, and proportions to practical situations. Ability to derive appropriate conclusions and apply on the job.
 
CORE COMPETENCIES
ATTENTION TO DETAIL 
   Double-checks the accuracy of information and work product to provide accurate and consistent work.
   Completes all work according to procedures and standards.
   Works in a conscientious, consistent, and thorough manner.
COMMUNICATION 
   Communicates and articulates clearly; is informative and appropriately concise.
   Asks questions freely to broaden knowledge and skills.
   Prepares clear and concise e-mails and other basic required written communications.
PROBLEM SOLVING & DECISION MAKING 
   Is objective; is able to evaluate facts apart from personal bias.
   Identifies key decisions within area of responsibility and escalates tasks to appropriate authority as needed.
   Effectively uses appropriate decision-making techniques.
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