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Utilization Management Non Clinical Jobs in Washington

Luminis Health

Utilization Management Nurse

Lanham, MD

$34 - $55/hr

Conducts concurrent and retrospective chart review for clinical, financial, and resource ... Monitors and identifies patterns or trends in utilization management; monitors potential and actual ...

Comagine Health

Clinical Reviewer DC

Washington, DC · On-site

The Clinical Reviewer position supports utilization management activities by assessing the medical ... Provide daily oversight and monitoring of non-clinical staff during their performance of non ...

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Utilization Management Non Clinical information

Can you do a utilization review without being a nurse?

Utilization Management Non Clinical roles typically do not require a nursing license, as they focus on reviewing medical necessity and appropriateness of services based on guidelines and policies. These positions often require strong analytical skills, knowledge of healthcare policies, and sometimes certifications like Certified Professional in Healthcare Quality (CPHQ), but do not usually mandate nursing credentials.

Which non-clinical healthcare jobs pay the most?

In non-clinical healthcare roles, positions such as healthcare administrators, health information managers, and utilization management directors tend to have the highest salaries. These roles often require advanced degrees, certifications, and strong management or technical skills, and they typically offer six-figure compensation depending on experience and location.

What jobs pay 4000 a week without a degree?

Utilization Management Non Clinical roles typically do not pay $4,000 a week without a degree, as they often require healthcare knowledge or certifications. High-paying jobs that can reach this level without a degree include certain sales positions, real estate brokers, or specialized trades like commercial pilots or skilled trades, which may require licenses or experience. Most roles paying this amount without a degree involve sales, entrepreneurship, or skilled labor with relevant certifications or experience.

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

AspectUtilization Management Non ClinicalUtilization Review Nurse
CredentialsCertifications like CCM, RN (optional), but primarily non-clinical certificationsRN license, certifications such as CCM or CUC
Work EnvironmentOffice-based, administrative setting, telecommuting optionsClinical settings, hospitals, or insurance companies, often with direct patient or provider interaction
Employer & Industry UsageHealth insurance companies, managed care organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentUnderstanding non-clinical roles in utilization managementClinical review roles involving direct patient care assessment

Utilization Management Non Clinical roles focus on administrative, policy, and documentation tasks without direct patient care, while Utilization Review Nurses perform clinical assessments to determine care necessity. Both roles are essential in healthcare utilization but differ mainly in clinical involvement and required credentials.

What is an example of a non-clinical position?

A non-clinical position in utilization management, such as Utilization Management Non-Clinical roles, involves reviewing medical records and insurance policies to determine coverage and appropriateness of care without direct patient interaction. These roles typically require knowledge of healthcare policies, strong analytical skills, and familiarity with healthcare management systems.
What are popular job titles related to Utilization Management Non Clinical jobs in Washington? For Utilization Management Non Clinical jobs in Washington, the most frequently searched job titles are:
What job categories do people searching Utilization Management Non Clinical jobs in Washington look for? The top searched job categories for Utilization Management Non Clinical jobs in Washington are:
Utilization Management Non Clinical jobs near you
Infographic showing various Utilization Management Non Clinical job openings in Washington as of July 2026, with employment types broken down into 100% Full Time. Highlights an 86% In-person, and 14% Remote job distribution.
Utilization Management Reviewer

Utilization Management Reviewer

AmeriHealth Caritas Health Plan

Washington, DC • On-site

Full-time

Medical, Retirement, PTO

Posted 8 days ago

AmeriHealth Caritas rating

8.3

Company rating: 8.3 out of 10

Based on 73 frontline employees who took The Breakroom Quiz

124th of 299 rated insurance

Job description

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of healthcare leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Role Overview
Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner.
Work Arrangement
  • Monday through Friday from 8:30 AM EST to 5:00 PM EST; 2 days must be worked in our DC office located at 1201 Maine Ave SW and 3 days can be worked remotely
  • Must work 4 recognized company holidays to include Thanksgiving and Christmas (rotating)
  • Weekends and overtime based on business need

Responsibilities
  • Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines
  • Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care
  • Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines
  • Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions
  • Identify and escalate complex cases requiring physician review or additional intervention
  • Ensure compliance with industry standards, including Medicare, Medicaid, and private payer requirements
  • Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Education & Experience
  • Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred
  • Minimum of 3 years of diverse independent clinical practice experience as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings
  • Experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient, outpatient and/or post acute services
  • Experience conducting utilization management reviews specific to a Medicare population across multiple states for a payer preferred

Licensure
  • An active and unencumbered Registered Nurse (RN) license in the District of Columbia required

Skills and Abilities
  • Competency in electronic health record (EHR) documentation and charting
  • Proficiency using MS Office to include Word, Excel, Outlook and Teams
  • Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance
  • Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment
  • Maintains a strong working knowledge of federal, state, and organizational regulations to ensure consistent application in the review process
  • Ability to type with accuracy and speed

Our Comprehensive Benefits Package
Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

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