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Online Utilization Review Jobs (NOW HIRING)

Banyan

Utilization Review Specialist

Pompano Beach, FL · On-site

$50K - $65K/yr

Utilization Review Specialist | Remote | Full-Time $50,000 - $65,000 Annually | Weekdays (Weekend Availability as Needed) Banyan Treatment Centers is seeking an experienced and detail-driven ...

Oscar Health

Utilization Review Nurse

Tempe, AZ · 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 regarding ...

Oscar Health

Utilization Review Nurse

Atlanta, GA · 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 regarding ...

ARcare

Utilization Review Associate

Augusta, AR · On-site

Utilization Review Associate Job Type: Full-time, 40 hours per week required (hourly POSITION SUMMARY Assist with planning and coordinating the duties of Utilization Review. This position is ...

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 regarding ...

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 regarding ...

US Tech Solutions

Utilization Review Nurse

Canton, MA · On-site

$55 - $60/hr

Ensure all utilization review activities meet regulatory turnaround time requirements. * Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.

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Online Utilization Review information

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How much do online utilization review jobs pay per hour?

As of Aug 10, 2026, the average hourly pay for online 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 the difference between Online Utilization Review vs Utilization Review Coordinator?

AspectOnline Utilization ReviewUtilization Review Coordinator
CredentialsTypically requires healthcare or insurance certifications, such as RN, CPC, or CCMOften requires similar certifications, with additional administrative or coordination training
Work EnvironmentRemote or office-based, reviewing patient records and insurance claims onlineOffice setting, coordinating reviews and communicating with providers and patients
Employer & IndustryHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare facilities, third-party review agencies

Online Utilization Review involves assessing medical necessity and coverage remotely using digital records, while Utilization Review Coordinator manages the review process, coordinating between providers and insurers. Both roles require similar credentials and are integral to healthcare and insurance industries, but Online Utilization Review is more focused on remote case assessments, whereas the Coordinator handles administrative oversight.

How do I get into an online utilization review?

To become an online utilization review specialist, you typically need a healthcare-related degree such as nursing, health administration, or a related field, along with experience in medical coding or insurance. Certification in utilization review, such as the Certified Professional in Healthcare Quality (CPHQ), can improve job prospects. Strong analytical skills and familiarity with medical records and insurance policies are also important for this role.

What are some common challenges faced by professionals in online utilization review, and how can they be addressed?

One common challenge in Online Utilization Review is staying up-to-date with changing regulations and payer requirements, which can impact approval criteria and documentation standards. Another challenge is effectively managing a high volume of cases while maintaining accuracy and meeting turnaround times. Building strong communication skills for collaborating with providers and interdisciplinary teams is also crucial. To address these challenges, professionals often participate in ongoing training, utilize clinical decision support tools, and foster open communication with team members and stakeholders.

What is an online utilization review?

An Online Utilization Review is a process in which healthcare professionals evaluate the necessity, efficiency, and appropriateness of medical services, procedures, or hospital admissions using digital platforms. This review is typically conducted remotely, using electronic health records and online communication tools to assess patient care. The goal is to ensure that patients receive the most effective care while avoiding unnecessary treatments and controlling healthcare costs. Online Utilization Review professionals may work for hospitals, insurance companies, or third-party administrators to maintain quality standards and compliance with regulations.

What are the key skills and qualifications needed to thrive as an online utilization review specialist?

To thrive as an Online Utilization Review Specialist, you need a solid background in nursing or healthcare, with credentials such as an RN or LPN license and experience in clinical review processes. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines and medical necessity criteria are typically required. Strong analytical thinking, attention to detail, and clear written communication help you effectively assess cases and interact with healthcare providers. These skills ensure accurate case reviews, compliance with regulations, and optimal patient care while controlling healthcare costs.
More about Online Utilization Review jobs
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Online Utilization Review jobs near you
Infographic showing various Online Utilization Review job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 89% Physical, 3% 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

South Burlington, VT • On-site

$135K - $155K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 22 days ago

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

Cobalt Benefits Group is an Equal Employment Opportunity Employer


Cobalt Benefits Group participates in E-Verify to confirm the employment eligibility of all new hires.