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Utilization Management Physician Reviewer Jobs (NOW HIRING)

University of Kentucky

Utilization Management Reviewer Requisition Number: R-000002878 Department Name: Supervisor ... with physicians, care teams, and ancillary staff to support effective discharge planning and ...

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How much do utilization management physician reviewer jobs pay per year?

As of Sep 3, 2026, the average yearly pay for utilization management physician reviewer in the United States is $37,992.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,000.00 and $42,000.00 per year, depending on experience, location, and employer.

What does a utilization management physician reviewer do?

A Utilization Management Physician Reviewer is a licensed physician who evaluates the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and hospital admissions. They review patient records and clinical information to ensure that care meets evidence-based guidelines and payer requirements. Their decisions help manage healthcare costs while ensuring patients receive necessary treatment. These professionals often work with insurance companies, hospitals, or managed care organizations.

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

To thrive as a Utilization Management Physician Reviewer, you need a valid medical degree (MD or DO), clinical experience, and licensure, often supplemented by board certification. Familiarity with utilization review guidelines, InterQual or MCG criteria, and electronic health record (EHR) systems is typically required. Strong analytical thinking, attention to detail, and effective communication help reviewers collaborate with providers and interpret complex medical data. These skills are crucial to ensuring appropriate, cost-effective patient care while adhering to regulatory and payer requirements.

What are the typical challenges faced by a utilization management physician reviewer, and how can they be addressed?

Utilization Management Physician Reviewers often encounter the challenge of balancing clinical judgment with payer policies and guidelines. They must make objective decisions about medical necessity, which can sometimes conflict with providers' recommendations or patient expectations. Effective communication and staying current with evolving healthcare regulations are crucial to address these challenges. Additionally, collaborating closely with multidisciplinary teams helps ensure thorough, fair reviews and fosters a supportive work environment.

What is the difference between Utilization Management Physician Reviewer vs Utilization Management Nurse Reviewer?

AspectUtilization Management Physician ReviewerUtilization Management Nurse Reviewer
CredentialsMedical degree, medical license, often board-certifiedNursing license, RN certification, possibly case management certification
Work EnvironmentHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare organizations, case management teams
Primary ResponsibilitiesReview medical necessity, approve or deny services, interpret clinical dataAssess patient records, review care plans, evaluate medical necessity from nursing perspective

While both roles involve reviewing healthcare services for appropriateness, the Utilization Management Physician Reviewer primarily makes decisions based on medical expertise and clinical judgment, whereas the Utilization Management Nurse Reviewer focuses on nursing assessments and care coordination. Both roles are essential in ensuring appropriate healthcare utilization within insurance and healthcare settings.

How to become a utilization management physician reviewer?

To become a utilization management physician reviewer, candidates typically need a medical degree, a valid medical license, and experience in clinical practice. Additional certifications such as board certification in a relevant specialty and knowledge of healthcare policies and coding can enhance qualifications. Familiarity with utilization review processes and documentation is also important.
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Cities with the most Utilization Management Physician Reviewer job openings:

What states have the most Utilization Management Physician Reviewer jobs?

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Utilization Management Physician Reviewer jobs near you
Infographic showing various Utilization Management Physician Reviewer job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 14% Part Time, and 2% Contract. Highlights an 89% Physical, 2% Hybrid, and 9% Remote job distribution, with an average salary of $37,992 per year, or $18.3 per hour.

RN UTILIZATION MGMT I

Covenant Health (Tennessee)

Knoxville, TN • On-site

Other

This job post has expired 2 days ago. Applications are no longer accepted.

Job description

Overview

Registered Nurse Utilization Management

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10 hospitals (http://www.covenanthealth.com/hospitals/) , outpatient and specialty services (http://www.covenanthealth.com/services/) , and Covenant Medical Group (http://www.covenantmedicalgroup.org/) , our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year. Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times.

Position Summary:

The RN Utilization Management I will perform utilization management functions to include medical necessity reviews to promote a utilization management program that operates 24 hours a day 7 days a week. Exhibits extraordinary leadership and professionalism in role. Prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement. Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. Utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting. Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus.

Responsibilities

  • Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.

  • Maintains accurate records of all communications and interventions related to utilization management.

  • Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.

  • Collaborates with UM Committee when applicable.

  • Collaborates with payor utilization management liaisons and medical directors as applicable.

  • Establishes effective rapport with other employees, professional support service staff, payors, patients, families and physicians.

  • Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.

  • Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.

  • Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:

  • Promote patient advocacy

  • Promote quality of care and/or life

  • Promote cost effective medical outcomes

  • Promote appropriate admission status

  • Provide continuity of care between utilization management and care coordinators

  • Coordinates/facilitates execution of notices (denials) of non-coverage when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.

  • Exhibits expertise in utilization management including but not limited to:

  • Knowing Medicare rules and regulations related to utilization

  • Knowing payor policies related to utilization management

  • Knowing Covenant Health’s Policies related to utilization management.

  • Keeping abreast of current changes affecting utilization management as applicable.

  • Performs well on internal audits thus promoting a culture of professional expertise in utilization management.

  • Provides monitoring and oversight of non-clinical utilization staff activities.

  • Provides advice and counsel to non-clinical precertification staff.

  • Assists with delayed claims review to determine appropriate number of observation hours as applicable in order for correct charges to be added to the patient’s account.

  • Assist with insurance requested audits and provides information to supervisor related to inaccurate and/or missing documentation as applicable.

  • Attends meetings as required and participates on committees as directed.

  • Performs other related duties as assigned or requested.

  • Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.

  • Supports, models and adheres to desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.

  • Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.

  • Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives and participates in quality improvement initiatives as requested.

  • Performs other duties as assigned.

Qualifications

Minimum Education:

None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.

Minimum Experience:

Three (3) years of acute care nursing experience; a minimum of two (2) years of experience in area of assigned responsibility. Prefer recent utilization management or case management experience.

Licensure Requirement:

Current licensure as a Registered Nurse (RN) as issued by the State of Tennessee. CCM/CPHQ certification preferred or equivalent expertise in area of Utilization Management as evidenced by performance.

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Job Title RN UTILIZATION MGMT I

ID 4621381

Facility Covenant Health Corporate

Department Name Utilization Management

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