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Prior Authorization Utilization Review Jobs in Reston, VA

CareMetx

Director, Pharmacy Operations

Bethesda, MD · On-site

$137K - $182K/yr

Prior authorization (PA) and appeals * Patient enrollment and case management * Operationalize ... Patient conversion rates * Program utilization and adherence * Leverage data to identify ...

Acentra Health

Clinical Reviewer-SCA

Mclean, VA · On-site

Assures accuracy and timeliness of all applicable review type cases within contract requirements ... Some knowledge of Case Management, UR and/or Prior Authorization or related experience is preferred

Maximus

Consultant - Medical (Case Reviewer 2)

VA · On-site +1

... action prior to review by medical and pharmacy review personnel. - Render medical/clinical ... hire). - Medical/Utilization Review experience. - Medicare Set-Aside Arrangement experience.

American Oncology Network

Financial Counselor

Bethesda, MD · On-site

$20.09 - $33.48/hr

... and prior authorization processes, including peer-2-peer and appeals, seeking support from provider or pharmacy team when applicable. * Review assigned patient(s) and/or Physician schedules for ...

American Oncology Network

Financial Counselor

Bethesda, MD · On-site

$20.09 - $33.48/hr

... and prior authorization processes, including peer-2-peer and appeals, seeking support from provider or pharmacy team when applicable. * Review assigned patient(s) and/or Physician schedules for ...

Discovery Behavioral Health

Program Therapist

Mclean, VA · On-site

$78K - $88K/yr

Communicates with the Utilization Review Department and Business Department regarding authorization ... Ensures discharge appointments are confirmed with patient and loved ones prior to discharge.

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Prior Authorization Utilization Review information

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$22

$43

$71

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

As of Aug 16, 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.

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.

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 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.

Director, Pharmacy Operations

CareMetx

Bethesda, MD • On-site

$137K - $182K/yr

Full-time

Re-posted 17 days ago

CareMetx rating

5.6

Company rating: 5.6 out of 10

Based on 9 frontline employees who took The Breakroom Quiz

195th of 224 rated it services

Job description

Description:

Director, Pharmacy Operations


POSITION SUMMARY: We are seeking a strategic and operationally strong leader to serve as Director / Senior Director of Pharmacy Operations. This role is responsible for leading pharmacy operations that support patient access to therapy through patient support programs, including free goods dispensing, bridge programs, and affordability initiatives.


This leader will oversee both pharmacy dispensing operations and patient access workflows, ensuring compliant, efficient, and patient-centric execution across the full journey—from referral through therapy initiation and fulfillment.


This role is ideal for leaders with experience in HUB services or specialty pharmacy.


Key Responsibilities

Pharmacy Operations & Dispensing Oversight

  • Lead pharmacy operations supporting free goods and patient assistance program (PAP) dispensing
  • Oversee prescription intake, verification, dispensing coordination, and fulfillment workflows
  • Ensure compliance with state board of pharmacy regulations, licensing requirements, and dispensing standards
  • Partner with pharmacists-in-charge (PIC) and clinical leadership to maintain safe and compliant operations

Patient Access & Program Execution

  • Oversee patient support workflows, including:
  • Benefits investigation (BI)
  • Prior authorization (PA) and appeals
  • Patient enrollment and case management
  • Operationalize manufacturer-sponsored programs, including:
  • Free goods (PAP)
  • Bridge / quick-start programs
  • Copay and affordability support
  • Ensure seamless coordination between access services and pharmacy dispensing

Program Strategy & Manufacturer Engagement

  • Partner with pharmaceutical manufacturers to design and execute patient support programs
  • Translate program requirements into scalable workflows across both access and dispensing functions
  • Support new product launches, including operational readiness, staffing, and training
  • Serve as a senior operational leader in client-facing discussions and program reviews

Performance Management & Analytics

  • Define and manage KPIs across both access and dispensing operations, including:
  • Time to therapy
  • Dispensing turnaround time
  • Patient conversion rates
  • Program utilization and adherence
  • Leverage data to identify inefficiencies and drive continuous improvement
  • Deliver executive-level reporting to internal stakeholders and manufacturer clients

Compliance, Quality & Risk Management

  • Ensure full compliance with:
  • HIPAA and patient privacy standards
  • State and federal pharmacy regulations
  • Manufacturer program requirements
  • Maintain audit readiness across both pharmacy and HUB operations
  • Oversee quality assurance, SOP development, and training programs

Leadership & Organizational Development

  • Build and lead high-performing teams across pharmacy operations, case management, and access services
  • Foster a culture of accountability, quality, and patient-centricity
  • Partner with Product, Technology, and Clinical teams to enhance systems and workflows

Required Qualifications

  • Bachelor’s degree required (Healthcare Administration, Business, Life Sciences, or related field)
  • 10+ years of experience in:
  • Pharmacy operations (including dispensing environments)
  • Patient support programs (PSP) / HUB services
  • Specialty pharmacy or access/reimbursement services
  • Experience overseeing or partnering closely with licensed pharmacy operations
  • Strong understanding of:
  • Benefits investigation and prior authorization workflows
  • Free goods / PAP program structures
  • Specialty pharmacy and PBM ecosystems
  • Proven leadership experience managing complex, multi-functional operations

Preferred Qualifications

  • Experience within Hub organizations or specialty pharmacy environments
  • Advanced degree (MBA, MPH, or similar)
  • Pharmacy Technician certification (CPhT) or similar (PharmD not required, but strong pharmacy operational knowledge preferred)
  • Experience supporting product launches or scaling new pharmacy programs
  • Familiarity with pharmacy management systems, HUB platforms, and workflow automation tools



Requirements:


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