$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 ...
$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 ...
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 ...
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 ...
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 ...
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 ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Care Transitions RN
Lincoln, NE · On-site
$68 - $90/hr
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
$68 - $90/hr
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Care Transitions RN
Lincoln, NE · On-site
Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting ...
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Quick apply
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Consults with Remote Utilization Review for precertification's, assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 15 ...
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Radiology - 2026-295
Omaha, NE · On-site
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Radiology - 2026-295
Omaha, NE · On-site
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Medicare Medical Director
Omaha, NE · On-site
The Medicare Medical Director is responsible for clinical, quality, care management, population ... Experience with utilization review/quality assurance, and direct case management. * Demonstrated ...
Medicare Medical Director
Omaha, NE · On-site
The Medicare Medical Director is responsible for clinical, quality, care management, population ... Experience with utilization review/quality assurance, and direct case management. * Demonstrated ...
The Medicare Medical Director is responsible for clinical, quality, care management, population ... Experience with utilization review/quality assurance, and direct case management. * Demonstrated ...
The Medicare Medical Director is responsible for clinical, quality, care management, population ... Experience with utilization review/quality assurance, and direct case management. * Demonstrated ...
Ophthalmology - 2026-064
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-064
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-018
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-018
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
PM&R RAF 2026-014
Omaha, NE · On-site
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
PM&R RAF 2026-014
Omaha, NE · On-site
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-063
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-063
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Urology - 2026-119
Omaha, NE · On-site
$17.50 - $21.75/hr
Surgeon will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Surgeon will utilize reasonable efforts to represent ...
Urology - 2026-119
Omaha, NE · On-site
$17.50 - $21.75/hr
Surgeon will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Surgeon will utilize reasonable efforts to represent ...
Ophthalmology - 2026-064
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
Ophthalmology - 2026-064
Omaha, NE · On-site
$16.75 - $22.50/hr
Physician will participate in quality assurance, utilization review, and continuous quality improvement activities of The Nebraska Medical Center. Physician will utilize reasonable efforts to ...
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?
| Aspect | Medical Utilization Review | Medical Claims Reviewer |
|---|---|---|
| Credentials | Certifications like CCM, RHIA, or RHIT often preferred | Certifications such as CPC or CCS beneficial |
| Work Environment | Healthcare facilities, insurance companies, or third-party review organizations | Insurance companies, healthcare payers, or claims processing centers |
| Primary Focus | Assessing necessity and appropriateness of medical services | Reviewing and processing insurance claims for payment |
| Industry Usage | Commonly used in healthcare and insurance sectors | Primarily 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:
$309K - $413K/yr
Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Posted 4 days ago
Job description
Summary
 Why should you join the BlueCross BlueShield of South Carolina family of companies?
Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
The Molecular Diagnostics Medicare Medical Director at Palmetto GBA oversees medical staff, analyzes utilization data, research emerging molecular technologies, and serves as a resource for providers and internal teams on policy issues. The role also includes developing, writing, and revising medical policies to ensure compliance and support Medicare coverage decisions.
Description
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Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This position is full-time (40-hours/week) Monday-Friday working REMOTE in the United States or ONSITE at our GPC location at 17 Technology Circle, Columbia, SC.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You'll Do:
Supports operations in the form of case review on both medical and regulatory matters. Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.
Educates staff and medical community on various aspects of medical policy and program administration.
May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
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 and technology.
To Qualify For This Position, You'll Need The Following:
Required Education: Doctorate degree Medical Doctor (MD) with current active license to practice medicine.
Required License and Certificate: Active state medical license and current board certification in a recognized specialty.
Required Work Experience: 5 years post graduate experience in direct patient care.
Required Skills and Abilities: Excellent verbal and written communication skills. Excellent customer service, organizational, and presentation skills.Proficiency in spelling, punctuation, and grammar. Ability to persuade, negotiate, or influence others. Ability to work as a team member as well as a leader. Knowledge of medical and utilization review techniques.
Required Software: Microsoft Office Suite.
We Prefer That You Have The Following:
Molecular Genetic Pathology fellowship training.
Medicare experience.
Experience interpreting medical evidence.
Scientific training/Research experience with publication history in Molecular Diagnostics.
Our Comprehensive Benefits Package Includes The Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers, and contribute their unique abilities to the growth of our company.
What to Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.
Pay Range Information:
Range Minimum
$206,011.00
Range Midpoint
$309,767.00
Range Maximum
$413,523.00
Pay Transparency Statement:
Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.comor call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's moreinformation.
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