Fishersville, VA · On-site
$35.43 - $54.21/hr
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
Fishersville, VA · On-site
$35.43 - $54.21/hr
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
... and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
... the MD review process to reflect appropriate utilization and compliance with SBU`s policies ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$122K - $162K/yr
This role provides oversight for drug utilization review, medication safety programs, and pharmacy ... Experience working with Medicare, Medicaid, and healthcare regulatory agencies * Knowledge of ...
Richmond, VA · On-site
$122K - $162K/yr
This role provides oversight for drug utilization review, medication safety programs, and pharmacy ... Experience working with Medicare, Medicaid, and healthcare regulatory agencies * Knowledge of ...
Arlington, VA · On-site
$368K - $460K/yr
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Arlington, VA · On-site
$368K - $460K/yr
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Arlington, VA · On-site
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Arlington, VA · On-site
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Arlington, VA · On-site
$407K - $460K/yr
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Arlington, VA · On-site
$407K - $460K/yr
... the MD review process to reflect appropriate utilization and compliance with SBU s policies ... Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector ...
Richmond, VA · On-site
$95 - $96/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$95 - $96/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Williamsburg, VA · On-site
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Richmond, VA · On-site
$95 - $100/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$95 - $100/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
$38.60 - $53.08/hr
Performs utilization review activities in accordance with Riverside Regional Medical Center ... Maintains knowledge and understanding of Medicare/Medicaid, Managed Care and other Payer ...
Richmond, VA · On-site
$95 - $109/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$95 - $109/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$95 - $109/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
Richmond, VA · On-site
$95 - $109/hr
... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ... Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector ...
$21.21 - $25.50
2% of jobs
$25.50 - $29.79
9% of jobs
$32.73 is the 25th percentile. Wages below this are outliers.
$29.79 - $34.08
21% of jobs
The median wage is $37.55 / hr.
$34.08 - $38.37
23% of jobs
$38.37 - $42.66
13% of jobs
$46 is the 75th percentile. Wages above this are outliers.
$42.66 - $46.95
10% of jobs
$46.95 - $51.24
8% of jobs
$51.24 - $55.53
5% of jobs
$55.53 - $59.82
5% of jobs
$59.82 - $64.11
2% of jobs
$64.11 - $68.40
2% of jobs
$21
$41
$68
A Medicare Utilization Review job involves evaluating healthcare services to ensure they meet Medicare guidelines for medical necessity, cost-effectiveness, and quality of care. Professionals in this role review patient records, treatment plans, and insurance claims to determine appropriate coverage and prevent fraud or overutilization. They work closely with healthcare providers and insurance companies to ensure compliance with federal regulations. This role helps maintain the integrity of Medicare services while optimizing patient care and cost efficiency. Strong analytical skills and knowledge of medical coding, billing, and Medicare policies are essential for success in this position.
In a Medicare Utilization Review role, your day-to-day tasks often include reviewing patient medical records to ensure services meet Medicare coverage criteria, evaluating the necessity and efficiency of proposed treatments, and communicating findings with healthcare providers. You’ll also submit detailed reports, coordinate with physicians, case managers, and insurance representatives, and follow up on documentation requests. Frequently, you’ll participate in interdisciplinary team meetings to discuss patient care plans and recommend alternative treatments if needed. This role requires balancing regulatory compliance with effective healthcare delivery, making each day dynamic and rewarding.
To thrive as a Medicare Utilization Review professional, you need a solid background in healthcare (often as an RN or LPN), strong analytical skills, and familiarity with Medicare regulations and guidelines. Experience using utilization management software, electronic health records (EHRs), and claim review systems like InterQual or MCG is typically required. Strong attention to detail, effective communication, and negotiation skills help set candidates apart. These competencies are crucial to ensure compliance, promote accurate claims processing, and support optimal patient care decisions within Medicare standards.
For Medicare Utilization Review jobs in Virginia, the most frequently searched job titles are:
The top searched job categories for Medicare Utilization Review jobs in Virginia are:
Cities in Virginia with the most Medicare Utilization Review job openings:
Fishersville, VA • On-site
$35.43 - $54.21/hr
Part-time
Medical, Retirement, PTO
Posted 26 days ago
The Utilization Review RN Case Manager applies knowledge of medical necessity criteria and regulatory requirements in determining the appropriate patient status for any person destined for a bed on the patient care units. This position works closely with admitting and attending providers as well as the Utilization Management Physician Advisor to ensure patient status is accurate and compliant with regulatory standards. The Utilization Review RN Case Manager is viewed by clinical teams as an expert in the building when it comes to selecting the appropriate level of service for patients. They participate in multidisciplinary discharge rounds on the hospital units to understand clinical course, discharge plans and possible changes in medical necessity, all toward selecting the levels of care that match clinical necessity. This position plays an essential role in securing reimbursement to the hospital for services provided by commercial, Medicaid and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of avoidable denials by payers for services provided. This role ensures adherence to the policies and guidelines of all payer review organizations to secure appropriate reimbursement for patient hospitalizations. During normal business hours this position may screen patients to determine if case management follow-up is required.
Minimum Qualifications
Preferred Qualifications
Skills
Some benefits of working at Augusta Health include
Company Information
Augusta Health is a mission-driven, independent, nonprofit, community health system located in Fishersville Virginia in Virginia’s scenic Shenandoah Valley. Augusta Health offers a full continuum of inpatient and outpatient which includes Augusta Medical Center a 255 bed inpatient facility and Augusta Medical Group which is comprised of 40 practice locations and four urgent care locations.
Equal Opportunity
Augusta Health recruits, hires and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.
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Hospitals
1,001 - 5,000 Employees
Fishersville, VA, US
