ZipRecruiter

Log In

2

Remote Utilization Review Jobs in Silver Spring, MD

CareFirst

Clinical Pharmacist (Remote)

Baltimore, MD · Remote

$117K - $140K/yr

Responsibilities will include but not are limited to; drug formularies, utilization management ... Reviews pharmacy market information and trends to develop and coordinate the implementation of ...

Lucyrx

Clinical Strategy Pharmacist

Bethesda, MD · On-site +1

$126K - $151K/yr

Lead formulary strategy development, including formulary design, tiering, utilization management ... Serve as a subject matter expert for P&T materials, clinical reviews, and formulary change ...

next page

Showing results 1-20

All JobsUtilization Review JobsRemote Utilization Review JobsRemote Utilization Review Jobs in Silver Spring, MD

Remote Utilization Review information

See Silver Spring, MD salary details

$22

$43

$71

How much do remote utilization review jobs pay per hour?

As of Jun 10, 2026, the average hourly pay for remote utilization review in Silver Spring, MD is $43.71, according to ZipRecruiter salary data. Most workers in this role earn between $34.52 and $50.19 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive in the Remote Utilization Review position, and why are they important?

To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.

What does a typical day look like for someone in a Remote Utilization Review role?

A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.

What is a Remote Utilization Review job?

A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.

What are the most commonly searched types of Utilization Review jobs in Silver Spring, MD? The most popular types of Utilization Review jobs in Silver Spring, MD are:
What are popular job titles related to Remote Utilization Review jobs in Silver Spring, MD? For Remote Utilization Review jobs in Silver Spring, MD, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Review jobs in Silver Spring, MD look for? The top searched job categories for Remote Utilization Review jobs in Silver Spring, MD are:
What cities near Silver Spring, MD are hiring for Remote Utilization Review jobs? Cities near Silver Spring, MD with the most Remote Utilization Review job openings:
Remote Utilization Review jobs near you
Infographic showing various Remote Utilization Review job openings in Silver Spring, MD as of June 2026, with employment types broken down into 81% Full Time, 6% Part Time, and 13% Contract. Highlights an 100% Remote job distribution, with an average salary of $90,917 per year, or $43.7 per hour.
SIU Nurse Auditor, RN, CPC (Full-time, Remote)

SIU Nurse Auditor, RN, CPC (Full-time, Remote)

Integrity Management Services, Inc.

Alexandria, VA • Remote

Full-time

Posted 4 days ago

Job description

Job Title: Clinical Nurse Auditor – Payment Integrity

Job Summary
We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a Registered Nurse (RN) with coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential, through AAPC or AHIMA. Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential.

How You Will Make an Impact

  • Investigations and Audits: Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
  • Tool and Policy Development: Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
  • Cross-Departmental Collaboration: Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
  • Data Analysis and Trending: Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
  • Fraud Detection Support: Support fraud investigators with medical review expertise to detect and address fraudulent activities.
  • Mentorship: Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Requirements

Qualifications

  • Education:
    • Minimum Associate’s Degree in Nursing required;
  • Licensure & Certification:
    • Current, unrestricted Registered Nurse (RN) license in applicable state(s).
    • Certification in medical coding from AAPC or AHIMA (e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
  • Experience:
    • Minimum 5 years of clinical nursing experience, preferably with exposure to hospital bill auditing or defense auditing.
    • Strong knowledge of provider manuals, reimbursement policies, and medical policy guidelines.
    • Prior experience with healthcare fraud investigation and auditing is highly preferred.
  • Skills:
    • Proficiency in CPT/HCPCS and ICD-10 coding, with a strong foundation in auditing, accounting, and control principles.
    • Analytical and problem-solving skills with a keen attention to detail.
    • Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
    • Strong proficiency in Microsoft Office and familiarity with audit tracking systems.

Preferred Traits

  • Meticulous, organized, and objective in analyzing claims and documentation.
  • Ethical and responsible, with a commitment to supporting the integrity of healthcare billing and reimbursement.
  • Able to work independently, stay current with rapidly changing healthcare regulations, and thrive in a fast-paced environment.