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Medical Utilization Review Jobs in Tennessee (NOW HIRING)

Sedgwick

RN Utilization Review

Knoxville, TN · On-site

$63K - $65K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... Utilization Review As a nurse at Sedgwick, you can build a meaningful and rewarding career while ... Apply your RN clinical knowledge and experience to assist in the management of complex medical ...

Sedgwick

RN Utilization Review

Memphis, TN · On-site

$63K - $65K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... Utilization Review As a nurse at Sedgwick, you can build a meaningful and rewarding career while ... Apply your RN clinical knowledge and experience to assist in the management of complex medical ...

Sedgwick

RN Utilization Review

Nashville, TN · On-site

$63K - $65K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... Utilization Review As a nurse at Sedgwick, you can build a meaningful and rewarding career while ... Apply your RN clinical knowledge and experience to assist in the management of complex medical ...

Acadia Healthcare

Utilization Specialist

Murfreesboro, TN · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conduct quality reviews for medical necessity and services provided. * Facilitate peer review calls ... Previous experience in utilization management is preferred LICENSES/DESIGNATIONS/CERTIFICATIONS:

Covenant Health

RN UTILIZATION MGMT I

Knoxville, TN

Registered Nurse Utilization Management Full Time, 80 Hours Per Pay Period, Day Shift Covenant ... Reviews precertification requests for medical necessity for all payors as applicable, referring to ...

Covenant Health

RN UTILIZATION MGMT I

Knoxville, TN · On-site

Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise. * Maintains accurate ...

TrustPoint Hospital

Utilization Specialist

Murfreesboro, TN

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conduct quality reviews for medical necessity and services provided. * Facilitate peer review calls ... Previous experience in utilization management is preferred LICENSES/DESIGNATIONS/CERTIFICATIONS:

Acadia Healthcare

Utilization Specialist

Murfreesboro, TN · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Conduct quality reviews for medical necessity and services provided. * Facilitate peer review calls ... Previous experience in utilization management is preferred LICENSES/DESIGNATIONS/CERTIFICATIONS:

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Medical Utilization Review information

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 Tennessee?

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

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

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

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

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

Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in Tennessee as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 15% Part Time, and 6% Contract. Highlights an 96% Physical, 2% Hybrid, and 2% Remote job distribution.

Manager of Utilization Review

ODYSSEY BEHAVIORAL GROUP

Franklin, TN • On-site, Remote

Full-time

Posted 24 days ago

Job description

Position Summary
The Manager of Utilization Review (UR) manages the daily operations of the UR practices for an assigned division. Leads This position ensures timely initial, concurrent, and retrospective reviews are conducted efficiently with a high degree of accuracy. The Manager of Utilization Review collaborates with leaders throughout the company to support denial prevention strategies, regulatory compliance and process optimization. This position serves as an internal subject matter expert and frontline people leader guiding and educating team members on UR functions, tracking and maintaining performance metrics, managing workflows and cross functional collaboration in support of organizational goals.
Relationships and Contacts
Within the organization: Maintains frequent and close working relationships with the Director of Utilization Review, Utilization Review Coordinators, Revenue Cycle team members, Admissions team members, Nursing leadership, milieu leadership, and all clinical team members.
Outside the organization: Initiates and maintains strong professional relationships with clients and families, insurance carrier contacts, referral partners and vendors, as needed.
Position Responsibilities
Essential Responsibilities
  1. Communicates professionally and effectively with multidisciplinary team members, insurance organizations and business offices, providing needed information in a logical, concise manner using technical language that accurately describes clients' condition(s) and treatment needs.
  2. Manages hiring and selection, onboarding training, regular coaching and supervision of Utilization Review Coordinators.
    1. Provides fair and consistent leadership and communication with team members.
    2. Promotes effective team dynamics within and between departments, facilitates team building and professional development for Utilization Review Coordinators.
  3. Assists team members with challenging cases, removing barriers and increasing access to care.
  4. Performs medical records reviews and ongoing training with clinical/medical team members within the assigned division.
  5. Performs regular audits of Utilization Review Coordinator's work to ensure quality and performance.
  6. Maintains current knowledge of Utilization Review process and trends, including denials and concurrent reviews.
  7. Revises processes in collaboration with the Director of Utilization Review to meet organizational goals, as needed.
  8. Utilizes effective documentation standards that support a strong historical record of actions taken on each account.
  9. Maintains a strict level of confidentiality for all client, company, departmental, and healthcare provider information.
  10. Escalates challenges and/or roadblocks to Director of Utilization Review for resolution, as needed.

Additional Responsibilities
  1. Maintains current knowledge of Utilization Review process, including denials and concurrent reviews.
  2. Functions within the guidelines of the corporate Code of Ethics and in accordance with Corporate Compliance standards.
  3. Reads, understands, adheres to, and models all company policy statements on ethics, conduct, and conflict of interests.
  4. Attends and completes all training within assigned time frames.
  5. Performs other duties as assigned.

Education and Experience
Position requires a bachelor's degree or equivalent in combined education and experience, and a minimum of three (3) years' experience with external review organizations or comparable entities doing pre-certification and concurrent reviews in mental health, substance abuse, and/or eating disorder facilities. Requires a comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using established facility criteria.
Physical Requirements
  • While performing the duties of this job, the employee will be required to communicate with peers/public, clients and/or vendors.
  • Tolerant to various noise levels: noise level in the work environment varies - may be very quiet to moderate.
  • Job performance will require the ability to sit or remain stationary for extended periods of time.
  • While performing the duties of this job, the employee may be required to talk or hear, sit, and stand.

Additional Requirements
  • Clearance of pre-employment tests, and any other mandatory state/federal requirements.

Skill Competencies
  • Demonstrates a proficient knowledge of medical and behavioral health terminology, and techniques used to diagnose and treat various medical conditions; including practices, standards of care, symptoms, treatment alternatives, medications used for treatment, and preventative healthcare measures.
  • Demonstrated ability to successfully function under pressure in critical situations.
  • Demonstrated ability to effectively manage conflict and crisis situations.
  • Demonstrates strong problem solving and analytical skills.
  • Demonstrates the ability to consistently exercise sound judgment and a high level of discretion.
  • Demonstrates excellent organizational and time management skills.
  • Demonstrates a high level of collaborative skills working with a variety of groups.
  • Demonstrates excellent interpersonal and relationship building skills.
  • Demonstrates a high level of follow-through and attention to detail.
  • Demonstrates excellent verbal and written communication skills.
  • Consistently demonstrates and models alignment with company core values and mission.
  • Demonstrate proficiency with technology resources to include Microsoft Office programs.

Odyssey Behavioral Healthcare, LLC and its subsidiaries provide equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunities apply to all terms and conditions of employment. Odyssey reserves the rights to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains "At-Will."

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