ZipRecruiter

Log In

1

Utilization Management Reviewer Jobs (NOW HIRING)

previous pagenext page

Showing results 21-40

All JobsHealthcare JobsNursing JobsNurse Case Manager JobsUtilization Management Reviewer Jobs

Utilization Management Reviewer information

See salary details

$31K

$38K

$44K

How much do utilization management reviewer jobs pay per year?

As of Sep 3, 2026, the average yearly pay for utilization management 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 reviewer do?

A Utilization Management Reviewer is responsible for evaluating medical records and healthcare services to ensure that patients receive appropriate and necessary care according to established guidelines and insurance policies. They review treatment requests, assess the medical necessity of procedures, and may coordinate with healthcare providers to clarify information. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients get the right level of care at the right time.

What are some common challenges utilization management reviewers face when balancing patient advocacy with cost containment?

Utilization Management Reviewers often encounter the challenge of ensuring that patients receive appropriate, evidence-based care while also adhering to insurance policy guidelines and cost-effectiveness requirements. This balancing act requires strong communication skills to collaborate with healthcare providers, as well as deep knowledge of clinical standards and insurance policies. Navigating disagreements between providers and payers can be difficult, but successful reviewers approach these situations with professionalism, empathy, and a commitment to fair, patient-centered decisions.

What are the key skills and qualifications needed to thrive as a utilization management reviewer, and why are they important?

To thrive as a Utilization Management Reviewer, you need a clinical background (often as an RN or LPN), strong understanding of medical necessity criteria, and experience in case review. Familiarity with utilization management software, health plan guidelines, and certifications like Certified Case Manager (CCM) are typically required. Attention to detail, critical thinking, and effective communication are essential soft skills for collaborating with providers and patients. These skills ensure appropriate care decisions, cost management, and regulatory compliance in healthcare delivery.
More about Utilization Management Reviewer jobs

What cities are hiring for Utilization Management Reviewer jobs?

Cities with the most Utilization Management Reviewer job openings:

What job categories do people searching Utilization Management Reviewer jobs look for?

The top searched job categories for Utilization Management Reviewer jobs are:

Utilization Management Reviewer jobs near you
Infographic showing various Utilization Management Reviewer job openings in the United States as of August 2026, with employment types broken down into 83% Full Time, and 17% Contract. Highlights an 67% In-person, and 33% Remote job distribution, with an average salary of $37,992 per year, or $18.3 per hour.

Clinical Care Reviewer UM

AmeriHealth Caritas Health Plan

Washington, DC • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 12 days ago

AmeriHealth Caritas rating

8.3

Company rating: 8.3 out of 10

Based on 73 frontline employees who took The Breakroom Quiz

132nd of 315 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

The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington DC area.
Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training.
AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more.
The targeted hiring range for this role is expected to be between $86,000.00 and $117,300.00 (or $41.35 and $56.39 per hour).
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.

What AmeriHealth Caritas employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply