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Prior Authorization Utilization Review Jobs in Reston, VA

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 ...

MedRisk

Clinical Reviewer

Washington, DC · On-site

Review types include Utilization Review and Continued Authorization (provide documented recommendations to adjusters and Nurse Case Managers based on use of appropriate guidelines.) * Reviews each ...

New

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 ...

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 ...

Pharmacy Careers

Formulary Management Pharmacist

Arlington, VA · On-site

$67 - $80.75/hr

Evaluate and review new drug products for formulary inclusion or exclusion. * Analyze clinical ... Provide clinical support for utilization management, prior-authorization criteria, and step-therapy ...

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All JobsPrior Authorization Utilization Review JobsPrior Authorization Utilization Review Jobs in Reston, VA

Prior Authorization Utilization Review information

See Reston, VA salary details

$22

$43

$71

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

As of Sep 6, 2026, the average hourly pay for prior authorization utilization review in Reston, VA is $43.99, according to ZipRecruiter salary data. Most workers in this role earn between $34.76 and $50.53 per hour, depending on experience, location, and employer.

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 Reston, VA?

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

What job categories do people searching Prior Authorization Utilization Review jobs in Reston, VA look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Reston, VA are:

What cities near Reston, VA are hiring for Prior Authorization Utilization Review jobs?

Cities near Reston, VA 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 Reston, VA as of August 2026, with employment types broken down into 82% Full Time, and 18% Part Time. Highlights an 100% In-person job distribution, with an average salary of $91,496 per year, or $44 per hour.

LPN Case Manager Clinical Authorization

MedStar Health

Washington, DC • On-site

$32.71 - $53.49/hr

Other

Posted 12 days ago

Medstar Health rating

7.8

Company rating: 7.8 out of 10

Based on 241 frontline employees who took The Breakroom Quiz

136th of 898 rated healthcare providers

Job description

About the Job
General Summary of Position
LPN Case Manager provides support for the Care Management Department by coordinating and promoting comprehensive quality, cost-effective care.
Primary Duties and Responsibilities
  • Assists in the identification of potential Case Management candidates through clinical review selected diagnoses etc. and makes appropriate referrals.
  • Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
  • Identifies and reports potential coordination of benefits subrogation third party liability workers compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.
  • Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests. Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care and education regarding the disease and support services.
  • Maintains current knowledge of MedStar Family Choice benefits and enrollment issues in order to accurately coordinate services.
  • Maintains expertise in general benefit management and serves as a resource for MedStar Family Choice members physicians and staff for benefit interpretation and coordination.
  • Maintains timely and accurate documentation in the IS System per Case Management policy.
  • Participates in meetings work groups etc. as assigned.
  • Processes pre-authorizations for medical necessity LOC covered benefits and participation of the provider at the discretion of the guidelines and Medical Reviewer.
  • Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications per policy.
Minimal Qualifications
Education
  • Valid LPN License in the State of Maryland. required
Experience
  • 1-2 years Utilization review experience required and
  • 3-4 years Diverse clinical experience required
Licenses and Certifications
  • LPN - Licensed Practical Nurse - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required
Knowledge Skills and Abilities
  • Knowledge of current trends in healthcare delivery and utilization review criteria.
  • Ability to use computer to enter and retrieve data.
  • Ability to create edit and analyze (Word Excel and PowerPoint) preferred

This position has a hiring range of
USD $32.71 - USD $53.49 /Hr.

What Medstar Health employees say

Pay

Benefits

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About Medstar Health

Sourced by ZipRecruiter

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Columbia, MD, US

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