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Prior Authorization Utilization Review Jobs (NOW HIRING)

Mission Hospital

RN - Utilization Review

Tuba City, AZ · On-site

$2.5K/wk

Utilization Review and Clinical Evaluation : * Review patient medical records, treatment plans, and ... prior authorization for treatments, procedures, or extended hospital stays. * Resolve any issues ...

Curant Health

Prior Authorization Pharmacist

Smyrna, GA · On-site

$58 - $69.75/hr

  • PTO

Coordinate drug utilization review reports and ensure compliance with regulatory requirements. * Handle clinical calls from Customer Care for medication-related prior authorizations. * Manage PA ...

Availity

Senior Product Director, Prior Authorization (Remote)

$238K - $249K/yr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... our Utilization Management (UM) product portfolio during a pivotal moment of industry ... Overseeing products supporting prior authorization, concurrent review, retrospective review, and ...

Umpqua Health

Utilization Review Nurse

$85K - $105K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Utilization Review Nurse Remote Ability to travel on-site to 3031 NE Stephens St., Roseburg OR ... This role conducts prior authorizations, facilitates care coordination, and supports safe ...

Umpqua Health

Utilization Review Nurse

$85K - $105K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

UTILIZATION REVIEW NURSE REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR ... This role conducts prior authorizations, facilitates care coordination, and supports safe ...

CentraCare Health

Prior Authorization Assistant

Saint Cloud, MN · On-site

$20.71 - $31.68/hr

  • Medical

  • Dental

  • Retirement

  • PTO

The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...

Axelon

Prior Authorization Clinician

Boston, MA · On-site

$50/hr

... utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines. • Determines medical necessity of each request by applying appropriate ...

New

Umpqua Health

Utilization Review Nurse

Roseburg, OR · On-site +1

$85K - $105K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

UTILIZATION REVIEW NURSE REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR ... This role conducts prior authorizations, facilitates care coordination, and supports safe ...

Umpqua Health

Utilization Review Nurse

Roseburg, OR · Remote

$85K - $105K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

UTILIZATION REVIEW NURSE REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR ... This role conducts prior authorizations, facilitates care coordination, and supports safe ...

Pacer Group

Prior Authorization Pharmacist (Remote)

$59.50 - $71.75/hr

Prior Authorization Pharmacist (Remote) Location: Remote (Must be able to work EST hours) Duration ... Knowledge of pharmacy benefit management and utilization review. Work Environment * Fully remote ...

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Prior Authorization Utilization Review information

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

As of Aug 17, 2026, the average hourly pay for prior authorization utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

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.

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.

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 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.

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 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.
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Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in the United States as of August 2026, with employment types broken down into 83% Full Time, and 17% Part Time. Highlights an 100% In-person job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review

Discovery Institute NJ

Marlboro, NJ

Full-time

Posted 24 days ago

Job description

Position Summary

The Utilization Review (UR) Specialist is responsible for obtaining and maintaining insurance authorizations for clients receiving substance use disorder treatment services. This position works closely with clinical staff, admissions, and insurance companies to ensure medical necessity documentation is accurate, authorizations are obtained timely, and reimbursement is maximized while maintaining compliance with payer requirements, Medicaid regulations, and accreditation standards.

Essential Duties and Responsibilities
  • Obtain initial and concurrent insurance authorizations for all levels of care.
  • Review clinical documentation to ensure it supports medical necessity.
  • Submit clinical information to insurance companies within required timeframes.
  • Monitor authorization expiration dates and request extensions before expiration.
  • Communicate authorization decisions and payer requirements to clinical staff.
  • Track approved days and notify leadership of denials or reductions in care.
  • Prepare and submit appeals for denied services when appropriate.
  • Maintain accurate authorization records in the electronic health record (EHR).
  • Work collaboratively with Admissions, Clinical, Nursing, and Billing departments.
  • Verify insurance benefits and coverage when necessary.
  • Monitor payer portals for authorization updates.
  • Assist with Medicaid and managed care authorization processes.
  • Participate in utilization review meetings and case conferences.
  • Generate reports on authorization status, denials, appeals, and payer trends.
  • Ensure compliance with Joint Commission, state, federal, and payer regulations.
  • Maintain confidentiality in accordance with HIPAA regulations.
  • Perform other duties as assigned.
Qualifications
  • High school diploma required; Associate's or Bachelor's degree preferred.
  • Minimum of two years of utilization review, case management, medical billing, or behavioral healthcare experience preferred.
  • Experience in substance use disorder or behavioral health treatment strongly preferred.
  • Knowledge of ASAM Criteria preferred.
  • Familiarity with Medicaid, commercial insurance, and managed care plans.
  • Strong organizational and time management skills.
  • Excellent verbal and written communication skills.
  • Ability to prioritize multiple cases in a fast-paced environment.
  • Proficient in Microsoft Office and electronic health record systems.
Knowledge, Skills, and Abilities
  • Understanding of insurance authorization processes.
  • Knowledge of medical necessity criteria and documentation standards.
  • Strong analytical and critical thinking skills.
  • Excellent customer service and professional communication.
  • Ability to work independently while collaborating with interdisciplinary teams.
  • Attention to detail and accuracy.
  • Ability to maintain confidentiality.
Performance Expectations
  • Maintain timely insurance authorizations with minimal lapses.
  • Reduce avoidable authorization denials.
  • Ensure documentation meets payer standards.
  • Maintain accurate records and reporting.
  • Demonstrate professionalism, teamwork, and excellent customer service.
  • Comply with all organizational policies, HIPAA, Joint Commission standards, and applicable federal and New Jersey regulations.

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