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Optum Health Utilization Review Jobs (NOW HIRING)

Prime Time Healthcare

Utilization Review

Washington, DC · On-site

Now Hiring: RN Utilization Review - Washington, DC Are you a passionate RN professional looking for ... Prime Time Healthcare is seeking dynamic individuals like you to join our team in Washington, DC ...

Prime Time Healthcare

Utilization Review

Baltimore, MD · On-site

Now Hiring: RN Utilization Review - Baltimore, MD Are you a passionate RN professional looking for ... Prime Time Healthcare is seeking dynamic individuals like you to join our team in Baltimore, MD and ...

Merrimack Health

Utilization Review Nurse

Lawrence, MA · On-site

Utilization Review Nurse Responsible for determining the appropriateness of hospital admission, utilization of resources and medical necessity for continued stay. Responsible for working with the ...

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Optum Health Utilization Review information

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How much do optum health utilization review jobs pay per hour?

As of Sep 14, 2026, the average hourly pay for optum health 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 an Optum Health Utilization Review?

An Optum Health Utilization Review job involves assessing medical necessity, appropriateness, and efficiency of healthcare services. Professionals in this role review patient records, insurance claims, and treatment plans to ensure compliance with industry standards and policies. They collaborate with healthcare providers, insurance companies, and patients to optimize care while managing costs. The position requires strong clinical knowledge, attention to detail, and familiarity with medical guidelines. It plays a crucial role in improving healthcare quality and reducing unnecessary expenses.

What are the key skills and qualifications needed to thrive in the Optum Health Utilization Review position?

To excel in an Optum Health Utilization Review role, you typically need a background in nursing or a related clinical field, a valid RN license, and familiarity with healthcare policies and guidelines. Experience with utilization management software, electronic medical records (EMR) systems, and potentially certifications such as CCM (Certified Case Manager) are highly valued. Strong analytical skills, attention to detail, and effective communication are important soft skills for evaluating medical necessity and collaborating with providers. These competencies ensure accurate, compliant review processes that support optimal patient care and organizational efficiency.

What are some common challenges faced by Optum Health Utilization Review specialists and how does the team address them?

Optum Health Utilization Review specialists often encounter challenges such as staying current with frequently changing healthcare regulations, handling complex medical cases, and managing high caseloads with tight deadlines. The team fosters a collaborative environment where members can consult with medical directors, other clinical reviewers, and support staff to resolve difficult cases and clarify policies. Regular training sessions, ongoing education, and access to up-to-date resources help team members stay informed and manage these challenges effectively. This supportive structure enables specialists to maintain high accuracy and efficiency while delivering quality outcomes for patients and providers.

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Optum Health Utilization Review jobs near you
Infographic showing various Optum Health Utilization Review job openings in the United States as of September 2026, with employment types broken down into 77% Full Time, 15% Part Time, and 8% Contract. Highlights an 77% In-person, and 23% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review

Marlboro, NJ • On-site

Discovery Institute
See more jobs at Discovery Instituteexternal

Other

Re-posted 12 days ago

Job description

Position Summary

The Utilization Review (UR) Specialist is responsible for obtaining and maintaining insurance authorizations for clients receiving substance use disorder treatment services. This position works closely with clinical staff, admissions, and insurance companies to ensure medical necessity documentation is accurate, authorizations are obtained timely, and reimbursement is maximized while maintaining compliance with payer requirements, Medicaid regulations, and accreditation standards.

Essential Duties and Responsibilities
  • Obtain initial and concurrent insurance authorizations for all levels of care.
  • Review clinical documentation to ensure it supports medical necessity.
  • Submit clinical information to insurance companies within required timeframes.
  • Monitor authorization expiration dates and request extensions before expiration.
  • Communicate authorization decisions and payer requirements to clinical staff.
  • Track approved days and notify leadership of denials or reductions in care.
  • Prepare and submit appeals for denied services when appropriate.
  • Maintain accurate authorization records in the electronic health record (EHR).
  • Work collaboratively with Admissions, Clinical, Nursing, and Billing departments.
  • Verify insurance benefits and coverage when necessary.
  • Monitor payer portals for authorization updates.
  • Assist with Medicaid and managed care authorization processes.
  • Participate in utilization review meetings and case conferences.
  • Generate reports on authorization status, denials, appeals, and payer trends.
  • Ensure compliance with Joint Commission, state, federal, and payer regulations.
  • Maintain confidentiality in accordance with HIPAA regulations.
  • Perform other duties as assigned.
Qualifications
  • High school diploma required; Associate's or Bachelor's degree preferred.
  • Minimum of two years of utilization review, case management, medical billing, or behavioral healthcare experience preferred.
  • Experience in substance use disorder or behavioral health treatment strongly preferred.
  • Knowledge of ASAM Criteria preferred.
  • Familiarity with Medicaid, commercial insurance, and managed care plans.
  • Strong organizational and time management skills.
  • Excellent verbal and written communication skills.
  • Ability to prioritize multiple cases in a fast-paced environment.
  • Proficient in Microsoft Office and electronic health record systems.
Knowledge, Skills, and Abilities
  • Understanding of insurance authorization processes.
  • Knowledge of medical necessity criteria and documentation standards.
  • Strong analytical and critical thinking skills.
  • Excellent customer service and professional communication.
  • Ability to work independently while collaborating with interdisciplinary teams.
  • Attention to detail and accuracy.
  • Ability to maintain confidentiality.
Performance Expectations
  • Maintain timely insurance authorizations with minimal lapses.
  • Reduce avoidable authorization denials.
  • Ensure documentation meets payer standards.
  • Maintain accurate records and reporting.
  • Demonstrate professionalism, teamwork, and excellent customer service.
  • Comply with all organizational policies, HIPAA, Joint Commission standards, and applicable federal and New Jersey regulations.

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