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Remote Insurance Utilization Review Jobs in Ohio

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Remote Insurance Utilization Review information

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What are remote insurance utilization review jobs?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What are the key skills and qualifications needed to thrive as a Remote Insurance Utilization Review Specialist, and why are they important?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.
What are the most commonly searched types of Insurance Utilization Review jobs in Ohio? The most popular types of Insurance Utilization Review jobs in Ohio are:
What are popular job titles related to Remote Insurance Utilization Review jobs in Ohio? For Remote Insurance Utilization Review jobs in Ohio, the most frequently searched job titles are:
What job categories do people searching Remote Insurance Utilization Review jobs in Ohio look for? The top searched job categories for Remote Insurance Utilization Review jobs in Ohio are:
What cities in Ohio are hiring for Remote Insurance Utilization Review jobs? Cities in Ohio with the most Remote Insurance Utilization Review job openings:
Remote Insurance Utilization Review jobs near you

Clinical Audit Specialist

On Demand / New Day Recovery LLC

Austintown, OH • On-site, Remote

Other

PTO

Re-posted 22 days ago

Job description

Recovery Management Services is seeking a detail-oriented and clinically experienced Clinical Audit Specialist to support behavioral health payer audit and denial management, utilization review, and medical necessity appeals for its counseling and residential detox organizations, On Demand Counseling and New Day Recovery.


This role is ideal for a clinician with strong documentation review skills, knowledge of ASAM Criteria, and experience navigating Medicaid, Medicare, MCO, and commercial payer requirements.


Hybrid or remote and flexible scheduling is available for qualified candidates seeking part-time work.

ESSENTIAL FUNCTIONS:

  • Coordinate and manage behavioral health payer audits, denials, and utilization review activities
  • Prepare and submit audit responses, appeals, and supporting clinical documentation
  • Defend medical necessity and level-of-care determinations using ASAM Criteria
  • Conduct peer-to-peer reviews and manage payer appeal processes
  • Monitor audit trends, documentation concerns, and compliance risks
  • Collaborate with clinical, compliance, and revenue cycle teams to improve payer outcomes and audit readiness
  • Provide documentation guidance and education related to medical necessity standards


REQUIRED QUALIFICATIONS:

  • Must be at least 18 years of age.
  • Successful completion of BCI/FBI background check and pre-employment drug screen
  • Active or eligible Ohio clinical licensure preferred, including LPC/LPCC, LSW/LISW, or related behavioral health credentials. Independent licensure preferred.
  • Clinical background with expertise in behavioral health documentation, medical necessity review, ASAM Criteria, and utilization review activities including audits and appeals.

SKILLS AND ABILITIES:

  • Strong clinical reasoning, critical thinking, and decision-making skills.
  • In-depth knowledge of behavioral health documentation standards and medical necessity criteria.
  • Working knowledge of HIPAA and 42 CFR Part 2 as they relate to audits and disclosures.
  • Proficiency with EHR systems and Microsoft Office.
  • Ability to manage multiple priorities and meet strict payer deadlines.
  • Clear, professional written and verbal communication skills.


BENEFITS

  • PTO begins accruing immediately.


EOO/DFWP

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