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Utilization Review Director Jobs in California (NOW HIRING)

KPC Health

Utilization Review Tech

Santa Ana, CA · On-site

Performs administrative duties for the Utilization Management Department, and directed in several ... Answer and review pertinent insurance correspondence to ensure complete and accurate reimbursement ...

KPC Global MSO

Utilization Review Tech

Santa Ana, CA · On-site

Reviews treatment plans and status of approvals from insurers. Collects and compiles data as ... Performs administrative duties for the Utilization Management Department, and directed in several ...

Medix

Utilization Review Nurse

Orange, CA · On-site

$38 - $53/hr

  • Medical

  • Dental

  • Vision

  • Retirement

Direct experience working within an IPA, MSO, Delegation model, or Health Plan setting. * Proven, hands-on experience navigating and applying MCG criteria for inpatient acute/SNF reviews.

Acadia Healthcare

Director of Utilization

San Rafael, CA · On-site

$105K - $130K/yr

We are seeking a Director of Utilization Review to lead utilization management processes that support appropriate care delivery, regulatory compliance, and effective use of patient benefits. This ...

Acadia Healthcare

Director of Utilization

San Rafael, CA · On-site

$105K - $130K/yr

We are seeking a Director of Utilization Review to lead utilization management processes that support appropriate care delivery, regulatory compliance, and effective use of patient benefits. This ...

Bayside Marin

Director of Utilization

San Rafael, CA · On-site

$105K - $130K/yr

We are seeking a Director of Utilization Review to lead utilization management processes that support appropriate care delivery, regulatory compliance, and effective use of patient benefits. This ...

Dignity Health

Utilization Review RN

Redding, CA · On-site

$69.95 - $93.81/hr

Understand how utilization management and case management programs integrate. * Ability to work as ... Thrive in a fast paced, self-directed environment. * Knowledge of CMS standards and requirements.

New

CommonSpirit Health

Utilization Review RN

Redding, CA · On-site

Understand how utilization management and case management programs integrate. * Ability to work as ... Thrive in a fast paced, self-directed environment. * Knowledge of CMS standards and requirements.

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Utilization Review Director information

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$41

$68

How much do utilization review director jobs pay per hour?

As of Aug 12, 2026, the average hourly pay for utilization review director in California is $41.73, according to ZipRecruiter salary data. Most workers in this role earn between $32.98 and $47.93 per hour, depending on experience, location, and employer.

What is the difference between Utilization Review Director vs Utilization Review Nurse?

AspectUtilization Review DirectorUtilization Review Nurse
CredentialsRN license, management experience, certifications (e.g., CCM)RN license, certification in case management or utilization review (e.g., CUC)
Work EnvironmentAdministrative, leadership roles overseeing teamsClinical, review of patient cases, direct patient care
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentLeadership, management, strategic planning in utilization reviewClinical review, case assessment, patient care coordination

The Utilization Review Director typically oversees review teams and manages utilization strategies, requiring leadership skills and management experience. In contrast, the Utilization Review Nurse focuses on clinical case assessments and patient care reviews. Both roles require RN licensure and relevant certifications but differ mainly in scope and responsibilities.

What does a utilization review director do?

A Utilization Review Director oversees the evaluation of medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead teams that review patient care requests, manage compliance with regulations, and implement strategies to ensure cost-effective care without compromising quality. Their responsibilities often include policy development, data analysis, and collaboration with healthcare providers to optimize resource use and improve patient outcomes.

Is utilization review a stressful job?

Utilization Review Directors often work in high-pressure environments where they must make quick, accurate decisions regarding healthcare services. The role can be stressful due to the need to balance patient care, insurance policies, and regulatory compliance, but stress levels vary based on workload, organizational support, and experience. Strong analytical skills and certification in utilization review can help manage job demands effectively.

What degree do I need for utilization review director?

A utilization review director typically needs at least a bachelor's degree in healthcare administration, nursing, or a related field. Many employers prefer candidates with a master's degree such as an MBA or a healthcare-related advanced degree, along with relevant experience and certifications like the Certified Professional in Healthcare Quality (CPHQ).

What are some common challenges faced by a utilization review director, and how can they be addressed?

A Utilization Review Director often navigates challenges such as balancing regulatory compliance with organizational goals, managing interdisciplinary teams, and keeping up with evolving healthcare policies. Staying proactive with ongoing education, fostering open communication among staff, and implementing efficient review processes can help address these issues. Additionally, leveraging data analytics and technology streamlines case reviews and ensures evidence-based decision-making, ultimately improving both patient outcomes and operational efficiency.

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

To thrive as a Utilization Review Director, you need a deep understanding of clinical guidelines, healthcare regulations, and case management principles, typically supported by a nursing or related healthcare degree and relevant licensure. Familiarity with utilization management software, electronic health records (EHR), and certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) is common in the field. Strong leadership, communication, analytical thinking, and decision-making skills help you effectively manage teams and ensure compliance. These competencies ensure efficient resource use, regulatory adherence, and high-quality patient outcomes within healthcare organizations.
What are the most commonly searched types of Utilization Review jobs in California? The most popular types of Utilization Review jobs in California are:
What cities in California are hiring for Utilization Review Director jobs? Cities in California with the most Utilization Review Director job openings:
Utilization Review Director jobs near you

Utilization Review Tech

KPC Health

Santa Ana, CA • On-site

Other

Posted 9 days ago

Job description

Utilization Review Technician

Under direction of the Utilization Review Technician Supervisor, the Utilization Review Technician coordinates with the Utilization Management Department while being responsible for coordinating phone calls, clinical requests, upkeeps data entry, organizes denials and mailing/faxing appeals, tracking data from various insurance providers and health plans regarding authorization and/or denials, expedite reviews and documentation to insurance providers. Monitors patient charts and records to provide to responsible parties and request for authorization for hospital admission. Reviews treatment plans and status of approvals from insurers. Collects and compiles data as required and according to applicable policies and regulations. Performs administrative duties for the Utilization Management Department, and directed in several aspects of duties. Position is non-RN/LVN.

Requirements
  • Ability to establish and maintain effective working relationships across the Health System
  • Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage
  • Follow up with insurance companies regarding the status of outstanding claims and necessary steps for resolution
  • Answer and review pertinent insurance correspondence to ensure complete and accurate reimbursement for medical claims
  • Responsible for working payer correspondence, edits and aged account receivable, and identifying and correcting billing errors
  • Pull daily reports utilizing Microsoft Excel and providing correct correspondence to payer
  • Research payer rules and regulations to maintain current payer knowledge
  • Comply with HIPAA and other compliance requirements to protect patient confidentiality
  • Manage data in internal and external databases with accuracy
  • Provide high-level administrative support and assistance to the Director and Supervisor or other assigned leadership staff
  • Perform clerical and administrative tasks including drafting letters, memos, invoices, reports, and other documents for senior staff
  • Prepare patient charts for medical audits
Education & Experience Requirements:
  • High School Diploma
  • Healthcare experience strongly preferred
Skills & Abilities Requirements:
  • Excellent verbal and written communication skills
  • Excellent organizational skills and attention to detail
  • Excellent time management skills with a proven ability to meet deadlines
  • Ability to function well in a high-paced and at times stressful environment
  • Extensive knowledge of office administration, clerical procedures, and recordkeeping systems
  • Able to type minimum of 50 words per minute
  • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
  • ICD-10 and CPT coding experience a plus
  • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
  • Extremely proficient with Microsoft Office Suite or similar software with the ability to learn new or updated software
  • Medical Terminology preferred
Physical Requirements:
  • Body Positions: Sitting and standing for prolonged periods.
  • Body Movements: Arm and hand dexterity.
  • Body Senses: Must have command of close and distant sight, color perception and hearing.
  • Strength: Ability to lift and move up to 25-pounds.
Working Environment:
  • Work in an office, where the climate is controlled.
  • OSHA exposure category: II
  • Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
  • Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
  • Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.
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About KPC Health

Sourced by ZipRecruiter

KPC Health has an integrated approach to serving the people of Riverside, San Bernardino and Orange County. Our acute care medical centers provide high quality, comprehensive and affordable healthcare for the entire family. For us, healthcare is not just about caring for our patients, but also about investing in the people throughout our communities. We are one team with one mission and that mission is for all our patients, and their families to Enjoy Life in Great Health.

Industry

Health care and social assistance

Company size

201 - 500 Employees

Headquarters location

Santa Ana, CA, US

Year founded

2004

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