ZipRecruiter

Log In

1

Prior Authorization Utilization Review Jobs (NOW HIRING)

Umpqua Health

Utilization Review Specialist

Roseburg, OR · Remote

$41K - $47K/yr

Utilization Review Specialist HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR ... Track prior authorization requests using established systems to ensure timely processing. * Support ...

next page

Showing results 1-20

All JobsPrior Authorization Utilization Review Jobs

Prior Authorization Utilization Review information

See salary details

$21

$42

$68

How much do prior authorization utilization review jobs pay per hour?

As of Jun 23, 2026, the average hourly pay for prior authorization 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 are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review Specialist, and why are they important?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.
More about Prior Authorization Utilization Review jobs
What cities are hiring for Prior Authorization Utilization Review jobs? Cities with the most Prior Authorization Utilization Review job openings:
What states have the most Prior Authorization Utilization Review jobs? States with the most job openings for Prior Authorization Utilization Review jobs include:
What job categories do people searching Prior Authorization Utilization Review jobs look for? The top searched job categories for Prior Authorization Utilization Review jobs are:
Prior Authorization Utilization Review jobs near you
Supervisor, Prior Authorization Utilization Management

Supervisor, Prior Authorization Utilization Management

Medical Mutual of Ohio

Cleveland, OH

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 11 days ago

Medical Mutual of Ohio rating

9.4

Company rating: 9.4 out of 10

Based on 15 frontline employees who took The Breakroom Quiz

13th of 261 rated insurance

Job description

Medical Mutual employees must submit their applications through MySource.
This is a hybrid-remote role based out of the Brooklyn, OH office, with employees expected to work onsite on designated in-office days each week.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Job Summary:
Supervises prior authorization utilization review nurses ensuring they appropriately apply medical necessity guidelines in making authorization determinations for preservice procedures and surgeries, in collaboration with physician reviewers. Oversees processes to support evidence-based guidelines, Corporate Medical Policies and other decision support tools to ensure comprehensive cost-effective care for members.
Responsibilities:
  • Supervises daily operations of assigned Prior Authorization Nurse Reviewers. Ensures appropriate use of staff resources to facilitate accurate and timely utilization management decisions in collaboration with physician reviewers.
  • Supports staff onboarding, training, and professional development including maintenance of current knowledge of approved criteria and evidence-based practice to support the delivery of high quality, efficient utilization management authorization determinations
  • Ensures that staff appropriately gather the requisite data and information to enter authorizations and tracks and monitors the accuracy and timelines of data entered
  • Evaluates the quality of individual and group performance to ensure that that team is meeting departmental and organizational goals related to utilization, cost, quality and productivity targets.
  • Ensures compliance with company policy and procedure as well as state and federal rules and regulations and accreditation standards.
  • Assists management in coordinating facility system process with providers, partners, vendors, and subcontractors as necessary
  • Performs other duties as assigned

Qualifications:
Education and Experience:
  • Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor of Science in Nursing preferred.
  • 7 years progressive experience as a Nurse Reviewer in health insurance prior authorization or clinical appeals, or equivalent relevant RN experience in a clinical practice
  • Relevant experience leading teams or projects (formally or informally)

Professional Certification(s):
  • Registered Nurse with current State of Ohio unrestricted license.

Technical Skills and Knowledge:
  • Intermediate Microsoft Office skills and proficiency navigating windows and web-based systems.
  • Knowledge of medical terminology/coding managed care processes
  • Knowledge of and the ability to apply fundamental concepts related to HIPAA compliance and related regulations
  • Knowledge of disease continuums expected patient outcomes and community services available
  • Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS code
  • Strong knowledge of health insurance benefits and network plan designs

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
  • We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
  • Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
  • On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
  • Discounts at many places in and around town, just for being a Medical Mutual team member.
  • The opportunity to earn cash rewards for shopping with our customers.
  • Business casual attire, including jeans.

Excellent Benefits and Compensation:
  • Employee bonus program.
  • 401(k) with company match up to 4% and an additional company contribution.
  • Health Savings Account with a company matching contribution.
  • Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
  • Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
  • Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
  • After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:
  • Career development programs and classes.
  • Mentoring and coaching to help you advance in your career.
  • Tuition reimbursement up to $5,250 per year, the IRS maximum.
  • Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
#LI-CS1 #LI-HYBRID
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

What Medical Mutual of Ohio employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply