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Medical Utilization Review Jobs (NOW HIRING)

Houston Healthcare

$80 - $100/hr

The Utilization Reviewer serves as a resource to medical and hospital staff on utilization and regulatory issues and participates in coordination of individualized patient care services. The ...

New

Washington Hospital

Utilization Review Liaison

Fremont, CA · On-site

$32.35 - $43.63/hr

Provides office and referral management support services; assists the Utilization Review Team in obtaining medical records, documenting case information in the system, performing data entry into ...

Sentara Health Plans

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site

$65 - $85/hr

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Ensures medical director written decision is consistent with criteria (CMS, state, medical policy ...

New

Sentara Healthcare

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site +1

The Utilization Review Nurse is responsible for utilization management services within the scope of ... Ensures medical director written decision is consistent with criteria (CMS, state, medical policy ...

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Medical Utilization Review information

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How much do medical utilization review jobs pay per hour?

As of Sep 4, 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.

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.
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Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 78% Full Time, 15% Part Time, and 6% Contract. Highlights an 92% Physical, 1% Hybrid, and 7% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

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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