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Utilization Management Auditor Jobs in Virginia (NOW HIRING)

Markon

Space Auditor

Herndon, VA · On-site

$110K - $125K/yr

Description Markon is seeking a qualified Space Planner / Space Auditor to support facility planning, occupancy management, and space utilization initiatives for a government customer. The selected ...

Markon

Space Auditor

Herndon, VA · On-site

$110K - $125K/yr

Description Markon is seeking a qualified Space Planner / Space Auditor to support facility planning, occupancy management, and space utilization initiatives for a government customer. The selected ...

Markon

Space Auditor

Herndon, VA · On-site

$110K - $125K/yr

Markon is seeking a qualified Space Planner / Space Auditor to support facility planning, occupancy management, and space utilization initiatives for a government customer. The selected candidate ...

Markon

Space Auditor with Security Clearance

Herndon, VA · On-site

$110K - $125K/yr

Markon is seeking a qualified Space Planner / Space Auditor to support facility planning, occupancy management, and space utilization initiatives for a government customer. The selected candidate ...

SC&H Group

Risk Senior Manager

Tysons Corner, VA

People Leadership & Practice Management (20%) * Manage, coach, and develop a team of managers ... Experience coordinating with external auditors and working in regulated industries (SaaS, fintech ...

Castro & Company

Audit Manager

Alexandria, VA · On-site +1

$111K - $145K/yr

Meet or exceed targeted billing hours (utilization), and monitor the budget to ensure that work is ... Three (3) years of management experience in Medicare cost report auditing, settlement, and ...

Castro & Company

Audit Manager

Alexandria, VA

$111K - $145K/yr

Meet or exceed targeted billing hours (utilization), and monitor the budget to ensure that work is ... Three (3) years of management experience in Medicare cost report auditing, settlement, and ...

Fairfax County

Financial Specialist II

Fairfax, VA · On-site

$70K - $122K/yr

... and compilation, auditing, oversight and review of third-party property management company ... Ability to plan and implement activities in order to ensure effective and efficient utilization of ...

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Utilization Management Auditor information

What is the difference between Utilization Management Auditor vs Utilization Review Nurse?

AspectUtilization Management AuditorUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or CUCLicensed Registered Nurse (RN), often with additional certifications
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinics, insurance companies, often in clinical settings
Primary FocusAuditing and reviewing utilization data for compliance and cost managementAssessing patient care needs and determining appropriate services

While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.

What are some common challenges faced by utilization management auditors and how can they be addressed?

Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.

What is a utilization management auditor?

A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.

What are the key skills and qualifications needed to thrive as a utilization management auditor?

To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.
What are popular job titles related to Utilization Management Auditor jobs in Virginia? For Utilization Management Auditor jobs in Virginia, the most frequently searched job titles are:
What job categories do people searching Utilization Management Auditor jobs in Virginia look for? The top searched job categories for Utilization Management Auditor jobs in Virginia are:
What cities in Virginia are hiring for Utilization Management Auditor jobs? Cities in Virginia with the most Utilization Management Auditor job openings:
Utilization Management Auditor jobs near you
Infographic showing various Utilization Management Auditor job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution.

Behavioral Healthcare Utilization Review Spec

Horizon Behavioral Heal

Lynchburg, VA • On-site

$46K - $74K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 16 days ago

Job description

Hours: full-time (37.5 hours per week)

Location: Lynchburg VA, 24501

Compensation dependent on experience


Position Summary

The Behavioral Healthcare Utilization Review Specialist works on-site, and will proactively monitor utilization of services for clients, reviewing for quality of services and medical necessity. The employee will review clients’ medical records to ensure appropriate utilization of treatment resources, medical necessity, proper documentation, and compliance with federal and state regulations, and certification requirements of insurance plans or other managed care organizations (MCOs). This position will report to the CQI Manager.

Education Requirements

  • Bachelor's degree from an accredited college/university in an applicable human services field. Preferred: Master’s degree in social work, Mental Health Counseling, or related health field preferred.

Types of Experience

  • (2) Two years of continuous quality improvement and/or utilization review experience. Preference will be given to individual with at least one year of managed care experience. Behavioral Health experience is desirable.
  • An equivalent combination of education and experience that provides the candidate with the required knowledge, skills and abilities may be considered.

Related Knowledge, Skills and Abilities

  • Knowledge of behavioral healthcare terminology, the course and progress of substance abuse treatment and medical terminology;
  • Knowledge of Medicaid and MCO regulations and policies, relevant to behavioral healthcare and substance use;
  • Knowledge of Utilization Review protocols and auditing skills;
  • Knowledge of DSM 5, CPT Codes and ICD 10;
  • Knowledge of levels of care and medical necessity;
  • Ability to review and understand medical records, treatment plans and progress notes;
  • Proficiency in MS Office software and EMR systems;
  • Ability to extract and analyze data;
  • Ability to develop and present statistical and narrative reports;
  • Must be proficient in MS Office software and EMR systems.
  • Able to collaborate with all members of clinical team/medical providers;
  • Excellent verbal and written communication skills;
  • Ability to work independently as well as with a team;
  • Excellent organizational and time management skills;
  • Willing and available to work modified schedules (weekends, holiday, etc.) as required;
  • Ability to drive and must possess a valid driver's license. May be required to travel to different Horizon worksites during the day based on operational needs or provide admin support at other locations. Regular attendance at trainings and Horizon meetings may require travel to a variety of Horizon sites.

THE BEST BENEFITS FOR THOSE WHO TAKE CARE OF THE COMMUNITY

We’re proud to offer some of the best benefits options in Central Virginia. Participation in the Virginia Retirement System (VRS) is exclusively for public service workers in Virginia, while several options exist for life, health, dental, and vision insurance. Emphasis on work-life balance means a generous annual leave policy ensuring time for wellness with separate time allocated for sick leave and additionally for paid holidays. Stay active with Horizon’s annual wellness programs and various opportunities to interact with the community through the year. Horizon’s clinical sites are NHSC/HRSA approved for clinical student loan repayment and qualify for both the Public Service Loan Forgiveness (PSLF) and the Behavioral Health State Loan Repayment (BHLRP) programs. If you are interested in continuing your education, working at Horizon qualifies you to receive discounts at some local universities.

To Apply – Please visit our online career center at https://www.horizonbh.org/careers/

Horizon Behavioral Health is an Equal Opportunity Employer (EOE).