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Utilization Management Clinical Analyst Jobs in Virginia

LinTech Global

Clinical Workflow Analyst IV

Fort Belvoir, VA · On-site

$100K - $125K/yr

  • Medical

  • Life

  • Retirement

  • PTO

The Clinical Workflow Analyst IV holds overall responsibility for managing MHS GENESIS incident ... Manage the complete lifecycle of MHS GENESIS incident and change request tickets using DHA ...

LinTech Global

Clinical Workflow Analyst IV

Fort Belvoir, VA · On-site

$100K - $125K/yr

  • Medical

  • Life

  • Retirement

  • PTO

The Clinical Workflow Analyst IV holds overall responsibility for managing MHS GENESIS incident ... Manage the complete lifecycle of MHS GENESIS incident and change request tickets using DHA ...

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All JobsUtilization Management Clinical Analyst JobsUtilization Management Clinical Analyst Jobs in Virginia

Utilization Management Clinical Analyst information

What does a utilization management clinical analyst do?

A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.

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

To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.

How does a utilization management clinical analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?

A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.

What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?

AspectUtilization Management Clinical AnalystUtilization Review Nurse
CredentialsHealthcare degree, certifications like CCM or CUCRegistered Nurse (RN), state licensure, certifications like CCM
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, insurance companies, outpatient facilities
Employer & IndustryHealth insurance providers, managed care organizationsHospitals, insurance companies, healthcare facilities
Common Search & ComparisonUtilization Management Clinical Analyst vs Utilization Review Nurse

The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.

What are popular job titles related to Utilization Management Clinical Analyst jobs in Virginia?

For Utilization Management Clinical Analyst jobs in Virginia, the most frequently searched job titles are:

What job categories do people searching Utilization Management Clinical Analyst jobs in Virginia look for?

The top searched job categories for Utilization Management Clinical Analyst jobs in Virginia are:

What cities in Virginia are hiring for Utilization Management Clinical Analyst jobs?

Cities in Virginia with the most Utilization Management Clinical Analyst job openings:

Utilization Management Clinical Analyst jobs near you
Infographic showing various Utilization Management Clinical Analyst job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 15% Part Time, and 3% Contract. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution.

Pharmacy Clinical Specialist - Medication Access Programs

Riverside

Newport News, VA

$133K - $193K/yr

Full-time

Re-posted 2 days ago

Job description

Newport News, Virginia

Hiring Range

$133,600.00 - $193,750.00/Annual Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs.
Overview
The Pharmacy Clinical Specialist - Medication Access Programs provides advanced clinical pharmacy services through a centralized medication access model supporting infusion, specialty, and ambulatory medication access programs. This role delivers comprehensive, evidence-based, safe, effective, and patient-centered medication management across ambulatory and infusion care settings while serving as a clinical resource for providers, pharmacy, nursing, and operational teams.The Pharmacy Clinical Specialist serves as the clinical lead for medication access strategy, therapy plan development, referral and site-of-care governance, payer and reimbursement optimization, and medication access workflow standardization across ambulatory and infusion settings. This role partners closely with providers, infusion operations, specialty pharmacy, revenue cycle, patient assistance, payer relations, and EPIC teams to facilitate timely and appropriate initiation of therapy through clinical oversight, evidence-based decision making, and coordinated medication access processes that improve speed-to-treatment, optimize patient and provider experience, reduce barriers to therapy initiation, strengthen financial stewardship, and support safe, compliant, and efficient delivery of medication access services across the enterprise.
What you will do
  • Lead medication access programs and specialty therapy initiatives through clinical oversight, therapy governance, and standardized medication access workflows
  • Deliver comprehensive patient-centered clinical pharmacy services through medication access, referral review, therapy optimization, and evidence-based medication management
  • Develop, implement, and maintain therapy plans and infusion readiness standards to support safe, timely, and efficient initiation of therapy
  • Optimize medication access, reimbursement, and site-of-care strategies through payer navigation, formulary management, financial stewardship, and barrier reduction
  • Advance pharmacy practice through quality improvement, workflow optimization, data-driven performance monitoring, education, and enterprise collaboration

Qualifications
Education
  • Bachelors Degree, or higher in Pharmacy (Required)

Experience
  • 1 year Completion of ASHP accredited post-graduate year 1 residency program, OR (Required)
  • 2 years Clinical Pharmacist Experience (Required)

Skills and Abilities
  • Knowledge of contemporary hospital/clinical practice and service. Significant knowledge and expertise in advanced pharmacy practice, specialty medication therapy management, and specialty evidence-based medicine in area appropriate for clinical assignments.
  • Ability to maintain professionalism in all communication and interactions both written and oral
  • Ability to lead assigned patient service lines, clinical areas, and therapeutic programs
  • Ability to facilitate pharmaceutical care services, patient care programs, medication utilization systems within assigned services and care areas to ensure drug utilization activities are aligned with patient care needs, evidence-based best practices, and regulatory standards
  • Advanced knowledge of clinical pharmacy practice, specialty medication management, infusion therapy, and evidence-based pharmacotherapy across ambulatory and infusion care settings
  • Ability to apply expertise in medication access, reimbursement, prior authorization, payer utilization management, and site-of-care optimization to improve patient access and financial stewardship
  • Strong clinical judgment and analytical skills to evaluate referrals, develop therapy plans, identify barriers to therapy initiation, and implement appropriate interventions
  • Proficiency in multidisciplinary collaboration and ability to effectively partner with providers, nursing, pharmacy, revenue cycle, patient assistance, and technology teams to coordinate patient care and operational outcomes
  • Ability to leads and support workflow redesign, quality improvement, and data-driven performance initiatives to improve efficiency, standardization, patient experience, and medication access outcomes
  • Maintain proficiency in healthcare technology and medication-use systems including electronic health records, therapy plan management, clinical decision support tools, and reporting platforms
  • Exhibits strong communication, facilitation, and change leadership skills with the ability to influence without direct authority, prioritize competing demands, and adapt to evolving clinical and operational needs

Licenses and Certifications
  • Licensed Pharmacist - Virginia Department of Health Professions (VDHP) within 60 Days(Required)
  • Board of Pharmacy Specialties (BPS) - Board of Pharmacy Specialties (Preferred)
  • CPR/BLS Certification - American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) (Preferred)
  • Valid Drivers License Required

To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.

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