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Medical Utilization Review Jobs (NOW HIRING)

Oscar Health

Utilization Review Nurse

Dallas, TX · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role ... You will perform frequent case reviews, check medical records and speak with care providers ...

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Oscar Health

Utilization Review Nurse

Miami, FL · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role ... You will perform frequent case reviews, check medical records and speak with care providers ...

New

UHS

Utilization Review Clinician

Augusta, GA

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

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How much do medical utilization review jobs pay per hour?

As of Jul 24, 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.
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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 July 2026, with employment types broken down into 1% As Needed, 78% Full Time, 14% Part Time, and 7% Contract. Highlights an 97% Physical, 1% Hybrid, and 2% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Utilization Review Specialist

Utilization Review Specialist

Lighthouse Behavioral Health Solutions

Columbus, OH • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired today. Applications are no longer accepted.

Job description

Lighthouse Behavioral Health Solutions (LBHS) offers a full continuum of care, including outpatient, intensive outpatient, partial hospitalization, residential treatment, psychiatric services, and medication‑assisted treatment. We take pride in creating a welcoming, compassionate environment where individuals feel supported. Our team believes in every client's ability to achieve recovery and rebuild meaningful, engaged lives in their communities.

Position: Utilization Review Specialist

Job Summary: The Utilization Review (UR) Specialist is responsible for ensuring that clients receiving substance use disorder (SUD) treatment services meet clinical criteria for admission, continued stay, and discharge. This role supports compliance with payer requirements, maintains proper documentation, and collaborates with clinical and administrative teams to maximize reimbursement while ensuring high-quality, medically necessary care.

Reports to: VP of Revenue Cycle Management

Duties and Responsibilities:

Duties include, but are not limited to:

  • Conduct initial and concurrent reviews to determine medical necessity using established criteria
  • Submit authorization requests and clinical documentation to insurance providers in a timely manner
  • Monitor authorizations and ensure services rendered align with approved levels of care
  • Track and manage authorization expirations and initiate reauthorization requests as needed
  • Review clinical records for completeness, accuracy, and compliance with payer and regulatory standards
  • Ensure treatment plans, progress notes, and discharge summaries support medical necessity
  • Provide feedback to clinical staff to improve documentation quality
  • Maintain adherence to HIPAA and confidentiality regulations
  • Serve as the primary liaison between the organization and insurance companies for utilization review matters
  • Participate in peer-to-peer reviews when required
  • Address denials by gathering supporting documentation and submitting appeals
  • Stay current with payer guidelines and regulatory changes affecting SUD services
  • Collaborate with clinical, admissions, billing, and case management teams to ensure continuity of care and proper utilization of services
  • Participate in multidisciplinary team meetings to discuss patient progress and level-of-care needs
  • Communicate authorization status and payer requirements to relevant staff
  • Maintain accurate records of authorizations, denials, and appeals
  • Track utilization metrics and identify trends to improve efficiency and reimbursement
  • Participate in audits and quality assurance initiatives
  • Perform other duties as assigned

Required Experience/Abilities:

  • Bachelor's degree in behavioral health, nursing, social work, or a related field required.
  • Knowledge of ASAM Criteria required
  • Minimum of 1 year of experience in utilization review, case management, or clinical services within behavioral health or SUD treatment
  • Experience working with commercial insurance, Medicaid, and/or Medicare preferred
  • Familiarity with electronic health record (EHR) systems
  • Must pass BCI check, all Corporate Compliance checks, and employment drug screen

Desired Experience/Abilities:

  • Master's degree or clinical licensure (e.g., LSW, LPC, LCSW, RN) preferred.3 years in a supervisory or management role within a behavioral health setting
  • Working knowledge of CPT and ICD-10 coding systems, with relevant certification (e.g., CPC, CCS-P) or equivalent experience
  • Understanding of medical necessity criteria, including experience with InterQual and/or Milliman (MCG) guidelines

Location: Columbus, OH

Our benefits package includes paid time off (PTO and sick time), paid holidays, medical/dental/vision, 401(k), life insurance, paid continuing education with supervision, parental leave, and eligibility for loan forgiveness programs.

LBHS is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, age, color, religion, sex, national origin, sexual orientation, disability status, genetics, gender identity and/or expression, protected veteran status, or any other characteristic protected by federal, state, or local law.

LBHS adheres to Title VII of the Civil Rights Act as amended, Ohio Civil Rights Act, and all applicable rules and regulations. LBHS is an equal opportunity employer.