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Medical Utilization Review Jobs (NOW HIRING)

Prime Healthcare

Utilization Review Tech

Lynwood, CA · On-site

$21 - $24.45/hr

Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles ... Utilization review tech is responsible for coordinating phone calls, data entry and tracking data ...

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Minimum of 1 year of experience working with clinical records, medical documentation, or utilization review, preferably in ABA therapy, behavioral health, or healthcare settings. * Proven experience ...

Apply Early

Mindful Health

Utilization Review Specialist

$25 - $30/hr

Utilization Review Specialist Mindful Health is a fast-growing company with the goal of providing ... Establish processes to verify the medical necessity and appropriateness of outpatient admissions

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Minimum of 1 year of experience working with clinical records, medical documentation, or utilization review, preferably in ABA therapy, behavioral health, or healthcare settings. * Proven experience ...

UHS

Utilization Review Coordinator

Augusta, GA

Review clinical content of medical records, participate in treatment team meetings, and collaborate ... utilization review. CERTIFICATIONS, LICENSES, REGISTRATION LMHC, LAPC, LPC, LMSW, LCSW, LPN or RN ...

Franciscan Health

Utilization Review Coordinator

Work From Home Work From Home Work From Home, Indiana 46544 The Utilization Review Coordinator performs admission screening for patients in a bed for medical necessity, and reviews for ...

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Medical Utilization Review information

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$21

$42

$68

How much do medical utilization review jobs pay per hour?

As of Jul 2, 2026, the average hourly pay for medical utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

Is being a MOA a good entry level job?

Medical Office Assistants (MOAs) often serve as entry-level healthcare support roles, requiring basic administrative and clinical skills. The position can provide valuable experience in medical settings and may lead to advancement with additional training or certifications. However, job responsibilities and requirements vary by employer and location.

What jobs pay 4000 a week without a degree?

Medical Utilization Review roles typically require relevant healthcare knowledge and certifications but may not always require a degree. High-paying jobs that can reach $4,000 a week without a degree include sales positions, real estate brokers, commercial pilots, and certain skilled trades like electricians or plumbers with experience. These roles often depend on experience, performance, or licensing rather than formal education.

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 utilization review a stressful job?

Medical utilization review can be stressful due to the need for accuracy, meeting strict deadlines, and managing complex cases. The role often requires attention to detail, critical thinking, and sometimes working under pressure, but stress levels vary depending on workload and work environment.

What qualifications do you need to be a utilization review nurse?

A utilization review nurse typically needs a registered nurse (RN) license, which requires completing an accredited nursing program and passing the NCLEX-RN exam. Relevant experience in case management, insurance, or clinical settings, along with knowledge of healthcare regulations and utilization review processes, is also important. Certification in case management or utilization review, such as the Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), can enhance job prospects.

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 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.
More about Medical Utilization Review jobs
What cities are hiring for Medical Utilization Review jobs? Cities with the most Medical Utilization Review job openings:
What states have the most Medical Utilization Review jobs? States with the most job openings for Medical Utilization Review jobs include:
What job categories do people searching Medical Utilization Review jobs look for? The top searched job categories for Medical Utilization Review jobs are:
Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in the United States as of June 2026, with employment types broken down into 48% Full Time, 35% Part Time, and 17% Contract. Highlights an 90% Physical, 2% Hybrid, and 8% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Director, Utilization Review

Cobalt Benefits Group LLC

Exeter, NH • On-site

$135K - $155K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 13 days ago

Be an early applicant

Job description

Description:

The Director of Utilization Review is responsible for the strategic leadership, operational execution, and regulatory compliance of the Utilization Review (UR) program. This role ensures clinically sound, timely, and compliant medical necessity determinations across all lines of business, while driving integration across Claims, Appeals, Stop Loss, and vendor partners. The position also advances technology-enabled utilization management, interoperability, and population health strategies in alignment with CBG’s operational and client objectives.


Clinical & Operational Leadership:

  • Provide leadership and oversight of the Utilization Review department
  • Ensure consistent, evidence-based medical necessity determinations
  • Establish and enforce clinical guidelines, documentation standards, and review protocols
  • Maintain alignment with MCG guidelines and internal clinical governance standards

Claims, Appeals & Stop Loss Integration:

  • Ensure seamless alignment between UR and Claims workflows
  • Provide clinical expertise and documentation support for Appeals processes
  • Partner with Stop Loss teams on high-cost claim reviews and determinations
  • Promote end-to-end workflow efficiency across clinical and administrative functions

Regulatory Compliance & Audit Readiness:

  • Ensure compliance with CMS, state, ERISA/non-ERISA, and accreditation requirements
  • Maintain audit-ready documentation and defensible clinical decisions
  • Oversee development and accuracy of denial and determination letters
  • Partner with Compliance and Legal to ensure regulatory alignment across all lines of business

Technology, Interoperability & Data Strategy:

  • Drive automation and digital workflow enhancements within UR
  • Enable interoperability across UR, Claims, Appeals, and vendor systems
  • Support real-time data exchange (EDI, integration platforms)
  • Leverage analytics to inform utilization trends, clinical outcomes, and population health initiatives

Quality, Training & Performance Management:

  • Establish quality assurance programs, audit processes, and performance standards
  • Develop and deliver training programs for clinical and operational staff
  • Implement dashboards and KPIs to measure productivity, compliance, and outcomes
  • Foster a culture of continuous improvement and accountability
Requirements:
  • Active Registered Nurse (RN) license
  • Minimum 5+ years of Utilization Review leadership experience
  • Strong knowledge of MCG guidelines, regulatory standards, and claims integration
  • Preferred experience within a TPA or health plan environment
  • Preferred familiarity with clinical platforms, workflow automation, and interoperability tools

Why Join Cobalt Benefits Group?

Cobalt Benefits Group is a trusted third-party administrator specializing in self-funded benefit plans. With over 30 years of experience and 180+ employees, we support employers through customized health plan administration, claims management, and specialized programs including FSAs, HSAs, COBRA, and retiree billing.

After a 60-day waiting period, full-time employees are eligible for a comprehensive benefits package, including:

  • Medical, dental, and vision coverage with employer HSA contributions
  • Company-paid life, AD&D, and disability insurance
  • 401(k) with up to a 6% employer match
  • Generous paid time off, sick time, and 10+ paid holidays
  • Flexible Spending Accounts
  • A collaborative culture with regular company events