ZipRecruiter

Log In

1

Utilization Management Jobs in Reston, VA (NOW HIRING)

MedStar Health

RN Utilization Management

Washington, DC · On-site

$89.07K - $162.80K/yr

... the management of quality health care resources for achievement of desired outcomes and ... Monitors utilization of all services for fraud and abuse. * Performs pre-authorization and pharmacy ...

MedStar Health

RN Utilization Mgmt

Washington, DC · On-site

$89.07K - $162.80K/yr

About the Job General Summary of Position The RN Utilization Manager will have 1-2 years of Utilization review- responsible for evaluating the necessity, appropriateness and efficiency of the use of ...

Pharmacy Careers

Appeals Pharmacist (Remote)

Ashburn, VA · On-site +1

$58.50 - $71.25/hr

Experience: Prior managed care or utilization management experience preferred - retail and hospital pharmacists with strong clinical and documentation skills are encouraged to apply. * Skills:

Pharmacy Careers

Appeals Pharmacist (Remote)

Annandale, VA · On-site +1

$57 - $69.50/hr

Experience: Prior managed care or utilization management experience preferred - retail and hospital pharmacists with strong clinical and documentation skills are encouraged to apply. * Skills:

next page

Showing results 1-20

People also search for

All JobsUtilization Management JobsUtilization Management Jobs in Reston, VA

Utilization Management information

See Reston, VA salary details

$40.5K

$93K

$169.3K

How much do utilization management jobs pay per year?

As of May 30, 2026, the average yearly pay for utilization management in Reston, VA is $92,960.00, according to ZipRecruiter salary data. Most workers in this role earn between $67,000.00 and $108,600.00 per year, depending on experience, location, and employer.

What is a Utilization Management job?

A Utilization Management (UM) job involves evaluating medical services to ensure they are necessary, cost-effective, and compliant with healthcare guidelines. Professionals in this field review patient care plans, authorize treatments, and collaborate with healthcare providers to optimize resource use. They work for insurance companies, hospitals, or healthcare organizations to balance quality care with cost control. Strong analytical skills and knowledge of medical policies are essential in this role.

What are the key skills and qualifications needed to thrive in the Utilization Management position, and why are they important?

To thrive in Utilization Management, you need a strong understanding of healthcare procedures, insurance guidelines, and case review processes, usually backed by a clinical background such as RN, LPN, or allied health certification. Familiarity with medical management software, electronic health records (EHR), and utilization review tools like InterQual or MCG is often required. Excellent analytical thinking, attention to detail, and effective communication skills greatly enhance performance in this role. These competencies enable accurate assessment of medical necessity, ensure regulatory compliance, and support efficient, collaborative workflows between providers, insurers, and patients.

What are the typical daily responsibilities of a Utilization Management professional?

As a Utilization Management professional, your day-to-day duties typically include reviewing patient admissions, authorizing ongoing treatment or procedures, assessing medical necessity, and ensuring services comply with insurance policies and industry guidelines. You will frequently collaborate with physicians, nurses, and insurance representatives to facilitate timely and appropriate care decisions while managing cost and quality. Documentation and communication play key roles as you help bridge the gap between clinical teams and payers. This role is often fast-paced, requires decisive action, and provides opportunities to have a direct impact on patient outcomes and organizational efficiency.
More about Utilization Management jobs
What are the most commonly searched types of Utilization Management jobs in Reston, VA? The most popular types of Utilization Management jobs in Reston, VA are:
What are popular job titles related to Utilization Management jobs in Reston, VA? For Utilization Management jobs in Reston, VA, the most frequently searched job titles are:
What job categories do people searching Utilization Management jobs in Reston, VA look for? The top searched job categories for Utilization Management jobs in Reston, VA are:
What cities near Reston, VA are hiring for Utilization Management jobs? Cities near Reston, VA with the most Utilization Management job openings:
Utilization Management jobs near you
RN Utilization Management

RN Utilization Management

MedStar Health

Washington, DC • On-site

$89.07K - $162.80K/yr

Full-time

Posted 6 days ago

Medstar Health rating

7.7

Company rating: 7.7 out of 10

Based on 237 frontline employees who took The Breakroom Quiz

158th of 864 rated healthcare providers

Job description

About the Job
General Summary of Position
Responsible for evaluating the necessity appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of acute care services based on Medically Necessity criteria the management of quality health care resources for achievement of desired outcomes and coordination of alternative levels of care in a timely and in the most cost-effective manner.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.
Primary Duties and Responsibilities
  • Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Acts as a liaison to MedStar Family Choice (MFC) contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
  • Acts as an advocate while assisting members to coordinate and gain access to medical psychiatric psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
  • Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups etc. as assigned. Provides input completes assignments and shares new findings with other staff. Participates in meetings and on committees and represents the department and MFC in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
  • Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
  • Demonstrates skill and flexibility in providing coverage for other staff.
  • Identifies inpatients requiring additional services and initiates care with appropriate providers. Demonstrates emphasis on quality patient care during the pre-admission and/or concurrent review process. Authorizes services according to MedStar Family Choice policy.
  • Initiates contact with providers to obtain clinical information to facilitate approval or pending of pre-authorization requests inpatient stays and retrospective reviews.
  • Maintains current knowledge of MFC benefits and enrollment issues in order to accurately coordinate services.
  • Maintains timely and accurate documentation in the clinical software system per Clinical Operations department's policy.
  • Monitors utilization of all services for fraud and abuse.
  • Performs pre-authorization and pharmacy reviews and documents in PBM's system when assigned.
  • Performs telephonic ACD line coverage for Clinical Operations' needs.
  • Performs telephonic inpatient utilization review services; on-site review as indicated. Process includes: assessment planning coordinating and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning as applicable.
  • Makes referrals to Case Management as needed.
  • Sends thorough reviews to Medical Director as appropriate. Coordinates timely review decisions and notifications per policy NCQA standards/guidelines and District of Columbia Contract.
  • Utilizes evidence-based standards in making coverage determinations in individual patient cases; Identifies and reports potential coordination of benefits subrogation third party liability worker's compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.

Minimal Qualifications
Education
  • Valid RN license in the District of Columbia; or Maryland required and
  • Bachelor's degree preferred

Experience
  • 1-2 years Recent utilization experience required and
  • 1-2 years Diverse clinical experience required

Licenses and Certifications
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia; or Maryland Upon Hire required and
  • CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred

Knowledge Skills and Abilities
  • Proficient computer skills to enter and retrieve data.
  • Ability to create edit and analyze Microsoft office (Word Excel and PowerPoint) preferred.
  • Knowledge of InterQual guidelines preferred.

This position has a hiring range of
USD $89,065.00 - USD $162,801.00 /Yr.

What Medstar Health employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Medstar Health logo

About Medstar Health

Sourced by ZipRecruiter

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Columbia, MD, US

Social media

FacebookTwitter

View All Medstar Health Jobs

Apply