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Prior Authorization Utilization Review Jobs in Ohio

Integrated Resources

Care Review Nurse

Columbus, OH · On-site

... prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum ... Background Hospital Utilization Management. Insurance Utilization Manager/Review and Millemen ...

Nationwide Children's Hospital

Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital ...

Sevita

Utilization Review Specialist

Akron, OH · On-site

$40K/yr

SUMMARY The Utilization Review Specialist is responsible for proactive planning measures, accurate ... Provides professional oversight of service delivery authorizations and assurances, effective ...

Equitas Health

Prior Authorization Specialist

Columbus, OH · On-site

$18.13 - $21.78/hr

Prior Authorization Specialist Established in 1984, Equitas Health is a regional not-for-profit ... For further information, please review the Know Your Rights notice from the Department of Labor.

TriHealth

Prior Authorization Specialist

Montgomery, OH · On-site

$17.25 - $23/hr

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical ...

TriHealth

Prior Authorization Specialist

Montgomery, OH · On-site

$17.25 - $23/hr

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical ...

TriHealth

Prior Authorization Specialist

Cincinnati, OH · On-site

$17.25 - $23/hr

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical ...

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Prior Authorization Utilization Review information

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 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.

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 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 popular job titles related to Prior Authorization Utilization Review jobs in Ohio?

For Prior Authorization Utilization Review jobs in Ohio, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Ohio look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Ohio are:

What cities in Ohio are hiring for Prior Authorization Utilization Review jobs?

Cities in Ohio 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 Ohio as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, 1% Temporary, and 2% Contract. Highlights an 93% Physical, 1% Hybrid, and 6% Remote job distribution.

Utilization Review (UR) Specialist

Blue Ash, OH • On-site

Communicarehealth
See more jobs at Communicarehealthexternal

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired 4 days ago. Applications are no longer accepted.

Job description

Job Address:

10123 Alliance Road, Suite 320 Blue Ash, OH 45242


UR Specialist.

Shift: M-Fr 8-5

This is not a remote position. It is an office-based position in Cincinnati, Ohio.

Who we are

At NewVista, the mission is to inspire hope and deliver holistic care to those in need of behavioral health services and addiction services in a safe and healing environment.We operate Behavioral Health Hospitals, Detox and Residential facilities, and a variety of other vertical line business that are here to support those who are seeking recovery.

The Role Itself

Position Summary:The Utilization Review Specialist is responsible for the authorizations and certifications process for Inpatient and Outpatient Services. This includes the precertification and recertification process, peer to peer reviews, and appeal. The UR Specialist will accurately report the authorization status of patients, denials and appeals status to the Corporate Director of UR.The UR Specialist will follow department and department procedures and ensure effective communication with all relevant departments regarding patient care needs.

JOB RESPONSIBILITIES

As Utilization Review Specialist, you will :

  • Obtain Continued Stay Reviews for Inpatient and Outpatient behavioral health treatment.
  • Follow up on prior authorization submissions that need further information to obtain authorization.
  • Display knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization, and advocates on behalf of the patient to secure coverage for needed services.
  • Strong working knowledge of external review organizations (ie: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
  • Report appropriate denial and authorization information to designated resource.
  • Coordinate authorization information with third party payors in a timely manner.
  • Complete thorough and accurate documentation in all required systems.
  • Maintain communication system based on documentation and verbal exchange regarding treatment with other UM staff and staff at the facilities as needed.
  • Schedule and follow up on results of Peer to Peer requests for physicians and CNP.
  • Maintain Denial Log

Education

  • High school diploma or GED (Required), Bachelor's Degree or Master's Degree in Nursing, Social Work, Mental Health/Behavioral Sciences, or related field preferred.
  • Previous Utilization Review experience in a behavioral healthcare facility preferred.
  • License: LPN, RN, LSW, LPC, LCDC or applicable license preferred

Skills

  • Ability to multi-task
  • Strong organization skills
  • Strong problem-solving skills
  • Ability to work well independently and as part of a team

Perks at Work

Healthcare:

  • Medical Packages with Rx - 3 Choices
  • Flexible Spending Accounts (FSA)
  • Dependent Day Care Spending Accounts
  • Health Spending Accounts (HSA) with a company match
  • Dental Care Program - 2 choices
  • Vision Plan
  • Life Insurance Options
  • Accidental Insurances
  • Paid Time Off + Paid Holidays
  • Employee Assistance Programs
  • 401k with a Company Match

Education + Leadership Development

  • Up to $15,000 in Tuition Reimbursements
  • Student Loan Forgiveness Programs

Our overall mission is to Inspire Hope, Restore Peace of Mind and Heal Lives.

Apply