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Prior Authorization Utilization Review Jobs in Washington

VSI

Insurance Authorization Specialist

Reston, VA · On-site

$19 - $25.25/hr

... prior authorization approvals and denials in addition to facilitating appeals and peer-to-peer reviews with the payer. * Responsible for insurance benefits verification. * Works directly with the ...

Luminis Health

Utilization Management Nurse

Lanham, MD

$34 - $55/hr

... reviews, care coordinators, and providers; reconciles and records days authorized in EPIC 2. Denial Management : Monitors and identifies patterns or trends in utilization management; monitors ...

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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 Washington?

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

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

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

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

Cities in Washington with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you

Clinical Care Reviewer UM

AmeriHealth Caritas Health Plan

Washington, DC • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 2 days ago

AmeriHealth Caritas rating

8.3

Company rating: 8.3 out of 10

Based on 73 frontline employees who took The Breakroom Quiz

129th of 311 rated insurance

Job description

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of healthcare leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Role Overview
Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner.
Work Arrangement
  • Monday through Friday from 8:30 AM EST to 5:00 PM EST; 2 days must be worked in our DC office located at 1201 Maine Ave SW and 3 days can be worked remotely
  • Must work 4 recognized company holidays to include Thanksgiving and Christmas (rotating)
  • Weekends and overtime based on business need

Responsibilities
  • Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines
  • Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care
  • Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines
  • Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions
  • Identify and escalate complex cases requiring physician review or additional intervention
  • Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements
  • Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Education & Experience
  • Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred
  • Minimum of 3 years of diverse independent clinical practice experience as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings
  • Experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient, outpatient and/or post acute services
  • Experience conducting utilization management reviews specific to a Medicare population across multiple states for a payer preferred

Licensure
  • An active and unencumbered Registered Nurse (RN) license in the District of Columbia required

Skills and Abilities
  • Competency in electronic health record (EHR) documentation and charting
  • Proficiency using MS Office to include Word, Excel, Outlook and Teams
  • Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance
  • Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
  • Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process
  • Ability to type with accuracy and speed

The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington DC area.
Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training.
AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more.
The targeted hiring range for this role is expected to be between $86,000.00 and $117,300.00 (or $41.35 and $56.39 per hour).
Our Comprehensive Benefits Package
Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

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