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Utilization Review Analyst Jobs (NOW HIRING)

Sheppard Pratt

Utilization Review Specialist

Towson, MD · On-site

$26.04/hr

Responsible for supporting the utilization review system including data analysis, report writing, and program improvement. * UR Specialist will develop and maintain a VOD Tracking and Receipt system.

HHC

UTILIZATION REVIEW SPECIALIST

Indianapolis, IN

FLSA Status Non-Exempt Job Role Summary The Utilization Review Specialist interacts with customers ... with strong analytical and organizational skills, and ability to work independently and under ...

tmn

Utilization Review Specialist

Akron, OH · On-site

$40K/mo

SUMMARY The Utilization Review Specialist is responsible for proactive planning measures, accurate ... Monitors strategies * Provides report analysis of actual service deliveries in comparison to ...

MNCP Staffing

Utilization Review Nurse

Las Vegas, NV

Duties include analyzing medical charts, determining whether care provided is within established ... Interquel or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies ...

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How much do utilization review analyst jobs pay per year?

As of Jun 5, 2026, the average yearly pay for utilization review analyst in the United States is $73,261.00, according to ZipRecruiter salary data. Most workers in this role earn between $52,500.00 and $87,000.00 per year, depending on experience, location, and employer.

What is a Utilization Review Analyst?

A Utilization Review Analyst is a healthcare professional who evaluates medical records and treatment plans to ensure that patients receive appropriate and cost-effective care. They review cases to determine medical necessity, compliance with insurance guidelines, and adherence to clinical standards. Utilization Review Analysts often work with healthcare providers, insurance companies, and regulatory agencies to optimize resource use and manage healthcare costs. Their work helps prevent unnecessary procedures and supports quality patient outcomes.

What are some common challenges Utilization Review Analysts face when coordinating with clinical and administrative staff?

Utilization Review Analysts often encounter challenges when balancing differing priorities between clinical providers and administrative policies. For example, clinicians may advocate for extended patient care based on medical judgment, while analysts must ensure that care aligns with insurance and regulatory guidelines. Effective communication and collaboration are essential, as analysts must diplomatically resolve discrepancies and provide clear rationale for decisions. Building strong relationships with both teams helps streamline the review process and fosters a collaborative work environment.

What are the key skills and qualifications needed to thrive as a Utilization Review Analyst, and why are they important?

To thrive as a Utilization Review Analyst, you need a solid understanding of healthcare regulations, medical terminology, and case management, typically supported by a degree in nursing, healthcare administration, or a related field. Familiarity with electronic medical records (EMR) systems, utilization management software, and certifications like Certified Professional in Utilization Review (CPUR) are often required. Analytical thinking, attention to detail, and strong communication skills help you effectively assess medical necessity and collaborate with healthcare providers. These skills ensure accurate and compliant review processes, leading to optimal patient care and efficient resource utilization.

What is the difference between Utilization Review Analyst vs Claims Analyst?

AspectUtilization Review AnalystClaims Analyst
CredentialsTypically requires healthcare-related certifications, such as RHIA or RHITOften requires insurance or claims processing certifications, like CPC or CPC-A
Work EnvironmentHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare payers, third-party administrators
Industry UsageUsed in healthcare and insurance sectors for reviewing medical necessityUsed in insurance and claims processing for evaluating claims

While both roles involve healthcare and insurance, a Utilization Review Analyst focuses on assessing the medical necessity of services, whereas a Claims Analyst handles processing and evaluating insurance claims. Both roles require understanding healthcare policies, but their daily tasks and focus areas differ.

More about Utilization Review Analyst jobs
What job categories do people searching Utilization Review Analyst jobs look for? The top searched job categories for Utilization Review Analyst jobs are:
Utilization Review Analyst jobs near you
Utilization Review Coordinator

Utilization Review Coordinator

Oceans Healthcare

Norman, OK • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 23 days ago

Oceans Healthcare rating

4.7

Company rating: 4.7 out of 10

Based on 13 frontline employees who took The Breakroom Quiz

Job description

Description
Full-time Utilization Review Coordinator
  • Associate's Degree with emphasis on healthcare or Bachelor's degree in social services field preferred.
  • At least one year psychiatric/chemical dependency experience with good working psychiatric/medical knowledge.
  • Utilization review experience REQUIRED

The Utilization Review Coordinator is responsible for management of all utilization review activities for the facility's inpatient, partial hospitalization, and outpatient programs. Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning. Coordinates information between third party payers and medical/clinical staff members. Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards.
Benefits We Offer:
Medical, Dental, Vision Coverage (Multiple Plan Options) - Eligible first of the month after 30 days.
401 (k) Retirement Savings Plan with Discretionary Company Match
Tuition Reimbursement
Daily Pay
Paid Time Off
Competitive Market Compensation
Short Term Disability, Long Term Disability
Life Insurance
Employee Assistance Program
Essential Functions:
  1. Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner.
  2. Conducts review of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to (1) determine appropriateness and clinical necessity of admissions, continued stay, and or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.e. H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and (3) identify any under-, over-, and/or inefficient use of services or resources.
  3. Reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems.
  4. Coordinates flow of communication between physicians/staff and third party payers concerning reimbursement requisites
  5. Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share with those attending any pertinent data from third-party payer contracts.
  6. Attends weekly treatment team.
  7. Conducts telephone reviews to, and follows through with documentation requests from third party payers.
  8. Maintains abstract with updates provided to third party payers.
  9. Notifies physicians/staff/patients of reimbursement issues.
  10. Initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received.
  11. Reports monthly all Hospital Issued Notices of Non-coverage (HINN letter) to QIO.
  12. Conducts special retrospective studies/audits when need is determined by M&PS and /or other committee structure.
  13. Ensures all authorization and denied information is in HCS at the end of each business day.
  14. Performs other duties and projects as assigned.

Requirements
Educational / Experience Requirements:
  • Associate's Degree with emphasis on healthcare or Bachelor's degree in social services field preferred.
  • At least one year psychiatric/chemical dependency experience with good working psychiatric/medical knowledge.

Qualifications/Skills:
  • Must have excellent assertive communication skills.
  • Knowledge and in-depth understanding of CD-psych treatment and discharge planning process.
  • Must have good writing and composition skills.
  • Must have good understanding of regulatory and fiscal reimbursement and utilization review as a primary component of patient care.
  • Must demonstrate strong patient advocacy skills.
  • Must be able to organize and prioritize high volume workload.
  • Must be able to analyze and utilize data and systems to provide individualized quality treatment in a cost-effective manner.
  • Must be able to function with minimal supervision.
  • Therapeutic Intervention De-escalation Education required.
  • Must have ability to maintain overall good work attitude and interact cooperatively and professionally with other staff members and third party payers to achieve mutually beneficial outcome.
  • Must possess basic competency in age, disability, and cultural diversity for needs of patients served and ability to relate to patients in a manner sensitive to those needs.
  • Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.

Work Environment:
Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.

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