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Prior Authorization Utilization Review Jobs in Washington

Luminis Health

Utilization Management Nurse

Annapolis, MD · On-site

$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 ...

Luminis Health

Utilization Management Nurse

Annapolis, MD · On-site

$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 ...

Gaudenzia

Clinical Review Clinician

Washington, DC · On-site

$85K/yr

... authorizations. This position requires a blend of clinical expertise, leadership skills, and a thorough understanding of utilization management to ensure the highest standards of care and compliance ...

Gaudenzia

Clinical Review Clinician

Washington, DC · On-site

$85K/yr

... authorizations. This position requires a blend of clinical expertise, leadership skills, and a thorough understanding of utilization management to ensure the highest standards of care and compliance ...

Comagine Health

Clinical Reviewer DC

Washington, DC · On-site

... prior to discharge. * Communicate timeline with the Client, internal team or providers and provide relevant information as appropriate. * Document utilization review decision in the appropriate ...

Comagine

Clinical Reviewer DC

Washington, DC · On-site

... prior to discharge. * Communicate timeline with the Client, internal team or providers and provide relevant information as appropriate. * Document utilization review decision in the appropriate ...

Direct Staffing Inc

Rn Mgr Utilization Mgmt

Hanover, MD · On-site

Reviews benefit systems and cost benefit analysis. * Evaluates medical, mental health and substance ... Prior managed care or insurance experience preferred. * Computer literate - MS Word, Excel, Outlook

New

Greenlife Healthcare Staffing

Be Seen First

Registered Nurse I

Washington, DC · On-site

$52/hr

No work on District holidays or administrative closure days without prior written approval. * Work ... Clinical experience in orthopedics, neurology, rehabilitation, or utilization review. * Skills:

ARM Consulting

Reimbursement Specialist

Fort Belvoir, VA · On-site

$21.75 - $30/hr

Prior Authorization Support & Access Navigation * * Review payer-specific prior authorization requirements * * Educate provider offices regarding payer documentation expectations * * Support ...

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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

Utilization Management Nurse

Luminis Health

Annapolis, MD • On-site

$34 - $55/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired 1 day ago. Applications are no longer accepted.

Luminis Health rating

7.9

Company rating: 7.9 out of 10

Based on 54 frontline employees who took The Breakroom Quiz

109th of 898 rated healthcare providers

Job description

Position Objective:  Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.  

Essential Job Duties:

1. Chart Review:

Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external 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 potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial;  assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.

3. Care Coordination:

Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.

4.  Process improvement initiatives

Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Educational/Experience Requirements:

  • Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience.  BSN must be achieved within 5 years of start date in the role.  
  • Three years of clinical nursing in an acute care hospital setting.

RequiredLicense/Certifications:

  • Current RN license from Maryland Board of Nursing.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range
$34—$55 USD

Luminis Health Benefits Overview:
•    Medical, Dental, and Vision Insurance
•    Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
•    Paid Time Off
•    Tuition Assistance Benefits
•    Employee Referral Bonus Program
•    Paid Holidays, Disability, and Life/AD&D for full-time employees
•    Wellness Programs
•    Employee Assistance Programs and more
*Benefit offerings based on employment status

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