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Prior Authorization Utilization Review Jobs in Michigan

Healthcare Support Staffing

Care Review Clinician

Troy, MI · On-site

$33 - $37/hr

Works with the Utilization Management team primarily responsible for inpatient medical necessity ... prior authorizations and/or concurrent review. * Assesses services for members to ensure optimum ...

Spectrum Health

Utilization Mgmt Spec

Southfield, MI · On-site

Completes required duties as defined for specific payers to obtain authorization numbers for payment. * Provides clerical support for Utilization Management; sorting faxes and mail, obtaining ...

New

Corewell Health

Utilization Mgmt Spec

Climax, MI · On-site

Completes required duties as defined for specific payers to obtain authorization numbers for payment. * Provides clerical support for Utilization Management; sorting faxes and mail, obtaining ...

New

JobRx, Inc.

Supervising Clinical Pharmacist

Watersmeet, MI · On-site

$110 - $150/hr

... utilization review activities to support safe, effective, and evidence-based prescribing. * Supports formulary management, including review of medication use patterns, prior authorization criteria ...

New

Integra Partners

Medical Coding Specialist

Troy, MI · On-site +1

$65K - $65K/yr

... Utilization Management operations, health plan implementations, prior authorization program ... Quality Review • Perform thorough self review of work prior to submission to ensure accuracy ...

Integra Partners

Medical Coding Specialist

Troy, MI · On-site

$65K/yr

... Utilization Management operations, health plan implementations, prior authorization program ... Quality Review • Perform thorough self review of work prior to submission to ensure accuracy ...

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All JobsPrior Authorization Utilization Review JobsPrior Authorization Utilization Review Jobs in Michigan

Prior Authorization Utilization Review information

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

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.

How do I get into a prior authorization utilization review?

To enter a prior authorization utilization review role, candidates typically need a background in healthcare, nursing, or health administration, along with knowledge of insurance policies and medical coding. Relevant certifications such as Certified Professional Coder (CPC) or Certified Utilization Review Professional (CURP) can enhance prospects, and experience with electronic health records (EHR) systems is often required.

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.

Is prior authorization utilization review a stressful job?

Prior authorization utilization review can be stressful due to the need for accuracy, attention to detail, and meeting strict deadlines. The role often involves reviewing medical documentation and making quick decisions, which can lead to pressure and workload challenges, especially during high-volume periods.

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.
What are popular job titles related to Prior Authorization Utilization Review jobs in Michigan? For Prior Authorization Utilization Review jobs in Michigan, the most frequently searched job titles are:
What job categories do people searching Prior Authorization Utilization Review jobs in Michigan look for? The top searched job categories for Prior Authorization Utilization Review jobs in Michigan are:
What cities in Michigan are hiring for Prior Authorization Utilization Review jobs? Cities in Michigan with the most Prior Authorization Utilization Review job openings:
Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in Michigan as of August 2026, with employment types broken down into 78% Full Time, 11% Part Time, and 11% Contract. Highlights an 100% In-person job distribution.

Director of Utilization Management

Integra Partners

Troy, MI • On-site, Remote

$160K - $160K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 11 days ago

Job description

Integra's Utilization Management (UM) division is looking for an experienced individual to direct the clinical and non-clinical utilization management teams for a managed care organization. This individual will play a key role in delivering UM to our health plan clients, growing our UM business, and working with the organization to operationalize our UM program.
JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES
The Director of Utilization Management's responsibilities include but are not limited to:
  • Prepare and maintain Utilization Review Plan policies and procedures
  • Obtain or maintain certification or license in states when performing Utilization Review
  • Work with Chief Medical Director to establish, adopt, and review UM benefit and medical necessity decision-making criteria
  • Manage UM Department, clinical and non-clinical staff, to ensure timely review of prior authorizations and appeals
  • Responsible for UM-related quality improvement activities, including conducting audits to ensure consistent application of medical criteria, evaluating program for improvement opportunities and annual IRR testing
  • Communicate and work with company executives and management to ensure alignment of UM program with departments and corporate initiatives
  • Participate on Quality Improvement Committee and UM Committee to oversee clinical oversight of UM Department
  • Work in conjunction with Account Managers and external liaison for clients to ensure program meets contractual delegated activities and performance requirements
  • As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities.
  • Help consult on existing and/or prospective client UM programs
  • Participate in technology related activities and implement solutions across UM Department
  • Oversee and execute the workplan to maintain NCQA certification
  • Build and manage the administrative and clinical resources to ensure the UR program functions efficiently and effectively, meeting all internal, legal, regulatory, and/or certification standards
  • Build and maintain a staffing model that is flexible and appropriate to scale as the business scales
  • Manage internal policies and procedures and workflows to ensure compliance, effectiveness, and best in class clinical operations
  • Owner of the third party technology and configuration of medical management software to ensure optimal operation
  • Responsible for day-to-day team management to ensure on-time, on-budget delivery of all operations • As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities
  • Help consult on existing and/or prospective client UM programs

WHAT WILL YOU LEARN IN THE FIRST 6 MONTHS?
  • In the first six months you will learn the function of the UM department within the organization and be fully integrated in your position, company, and team
  • You will have a full and complete understanding of our metric requirements and reporting capabilities
  • You will understand your role and responsibilities, to foster excellence in team performance
  • You will develop team goals and monitor progress, as you build relationships with your team to encourage and understand their needs and abilities
  • During this time, you will set measurable goals for personal development and growth

WHAT WILL YOU ACHIEVE IN THE FIRST 12 MONTHS?
  • You will create a people first approach to your team, easily identifying the strengths and weakness of each team member and how to best support them
  • You will be contributing your skills and knowledge to meet your department's metrics and goals

EXPERIENCE:
  • Bachelor's degree in area of specialty, preferred
  • Minimum of 10 years of UM management experience in a managed care setting
  • Experience with UM NCQA or URAC certification/accreditation
  • Experience with leading and managing teams of clinical and non-clinical staff
  • Analytical ability and clinical knowledge in order to assess medical records, identify trends, and report findings
  • Communication skills, verbal and written, needed to convey information clearly and consistently
  • Interpersonal skills necessary to develop and maintain a wide variety of cooperative working relationships

Salary: $160,000.00/Annually
Benefits Offered
  • Competitive compensation and annual bonus program
  • 401(k) retirement program with company match
  • Company-paid life insurance
  • Company-paid short term disability coverage (location restrictions may apply)
  • Medical, Vision, and Dental benefits
  • Paid Time Off (PTO)
  • Paid Parental Leave
  • Sick Time
  • Paid company holidays and floating holidays
  • Quarterly company-sponsored events
  • Health and wellness programs
  • Career development opportunities

Remote Opportunities
We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.
Our Story
Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.
With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We're looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.
Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don't hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.

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