Responsibilities The Utilization Review Director is responsible for directing and overseeing the Utilization Management Department. This includes the implementation of case management scenarios ...
Responsibilities The Utilization Review Director is responsible for directing and overseeing the Utilization Management Department. This includes the implementation of case management scenarios ...
RN - Utilization Review
Fort Myers, FL · On-site
Utilization Review Manager In this role, you will manage utilization review processes, ensuring quality patient care while optimizing resource use. Your responsibilities include assessing patient ...
RN - Utilization Review
Fort Myers, FL · On-site
Utilization Review Manager In this role, you will manage utilization review processes, ensuring quality patient care while optimizing resource use. Your responsibilities include assessing patient ...
Performs utilization review and management, including quality review, case review for third party payers' requirements. Ensures optimal reimbursement from governmental third-party payers', obtaining ...
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Performs utilization review and management, including quality review, case review for third party payers' requirements. Ensures optimal reimbursement from governmental third-party payers', obtaining ...
Manager, Utilization Review
Tampa, FL · On-site
Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure effective ...
New
Manager, Utilization Review
Tampa, FL · On-site
Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure effective ...
New
Manager, Utilization Review
Tampa, FL · On-site
Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure effective ...
New
Manager, Utilization Review
Tampa, FL · On-site
Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure effective ...
New
Manager, Utilization Review
Tampa, FL · On-site
A Brief Overview Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure ...
New
Manager, Utilization Review
Tampa, FL · On-site
A Brief Overview Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure ...
New
Through services including benefits verification, billing and claims submission, and utilization review, we help treatment centers optimize revenue cycle management while focusing on delivering ...
Through services including benefits verification, billing and claims submission, and utilization review, we help treatment centers optimize revenue cycle management while focusing on delivering ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Overview The Manager of Utilization Review provides operational leadership and oversight for ... Minimum five (5) years of Utilization Management, Case Management, Revenue Cycle, or Denials ...
Overview The Manager of Utilization Review provides operational leadership and oversight for ... Minimum five (5) years of Utilization Management, Case Management, Revenue Cycle, or Denials ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Utilization Review Nurse
Bradenton, FL · On-site
Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly ...
Revenue Cycle Management : Utilize clinical expertise to support revenue cycle processes, including ... Utilization Review: a) Apply medical necessity screening criteria and clinical knowledge to ensure ...
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Revenue Cycle Management : Utilize clinical expertise to support revenue cycle processes, including ... Utilization Review: a) Apply medical necessity screening criteria and clinical knowledge to ensure ...
Utilization Review Nurse
Cooper City, FL · On-site
Revenue Cycle Management : Utilize clinical expertise to support revenue cycle processes, including ... Utilization Review: a) Apply medical necessity screening criteria and clinical knowledge to ensure ...
Utilization Review Nurse
Cooper City, FL · On-site
Revenue Cycle Management : Utilize clinical expertise to support revenue cycle processes, including ... Utilization Review: a) Apply medical necessity screening criteria and clinical knowledge to ensure ...
At least 2 years of experience in utilization review, case management, or clinical healthcare roles. * Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
At least 2 years of experience in utilization review, case management, or clinical healthcare roles. * Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines ... Experience Proven experience in utilization review or utilization management within hospital or ...
Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines ... Experience Proven experience in utilization review or utilization management within hospital or ...
Manage authorizations for Detox, Residential, and PHP levels of care across adult and adolescent Mental Health and SUD programs. * Review clinical documentation to ensure that it clearly supports ...
New
Manage authorizations for Detox, Residential, and PHP levels of care across adult and adolescent Mental Health and SUD programs. * Review clinical documentation to ensure that it clearly supports ...
New
Utilization Review Coordinator Location: Everwell Port St. Lucie Hospital, Inc Position Summary ... Adept in identifying potential problems within the department and seeks management guidance.
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Utilization Review Coordinator Location: Everwell Port St. Lucie Hospital, Inc Position Summary ... Adept in identifying potential problems within the department and seeks management guidance.
Utilization Review Coordinator Location: Everwell Port St. Lucie Hospital, Inc Position Summary ... Adept in identifying potential problems within the department and seeks management guidance.
Utilization Review Coordinator Location: Everwell Port St. Lucie Hospital, Inc Position Summary ... Adept in identifying potential problems within the department and seeks management guidance.
Utilization Review Management information
What is utilization review management?
Utilization Review Management is a process used in healthcare to evaluate the necessity, appropriateness, and efficiency of medical services, procedures, and facilities. Its primary goal is to ensure that patients receive appropriate care while preventing unnecessary or duplicative services. Utilization Review Management helps healthcare providers and insurance companies manage costs, maintain high-quality care, and comply with regulations. Professionals in this field often review patient records, coordinate with clinicians, and make recommendations about coverage or care plans.
What are the key skills and qualifications needed to thrive in utilization review management?
To thrive in Utilization Review Management, you need a solid background in healthcare, strong analytical skills, and often a clinical degree such as RN or LPN, with certification in utilization review or case management being highly beneficial. Familiarity with medical coding systems (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required. Excellent communication, critical thinking, and negotiation skills help you collaborate with providers and payers while advocating for patient care. These competencies are vital for ensuring appropriate resource use, regulatory compliance, and optimal patient outcomes.
What are some common challenges faced by professionals in utilization review management, and how can they be addressed?
Professionals in Utilization Review Management often encounter challenges such as balancing regulatory compliance with patient advocacy and managing high caseloads under tight deadlines. Navigating complex insurance policies and ensuring timely communication between healthcare providers and payers can be demanding. Staying organized, leveraging technology for workflow management, and participating in ongoing training can help address these challenges. Additionally, strong collaboration with interdisciplinary teams ensures more effective and efficient utilization review processes.
What is the difference between Utilization Review Management vs Utilization Review Nurse?
| Aspect | Utilization Review Management | Utilization Review Nurse |
|---|---|---|
| Credentials | Typically requires a healthcare management or related certification, sometimes a nursing background | Registered Nurse (RN) license, often with additional utilization review certification |
| Work Environment | Office-based, administrative setting, collaborating with healthcare providers and insurance companies | Clinical setting, reviewing patient charts, and making utilization decisions |
| Employer & Industry | Health insurance companies, managed care organizations, healthcare administrators | Hospitals, insurance companies, healthcare facilities |
Utilization Review Management professionals focus on overseeing review processes, policy compliance, and administrative tasks, while Utilization Review Nurses conduct clinical assessments to determine appropriate care. Both roles are essential in healthcare utilization management but differ in responsibilities and work environment.
How do I get into utilization review management?
To enter utilization review management, candidates typically need a background in healthcare, nursing, or a related field, along with knowledge of medical billing and coding. Obtaining relevant certifications such as the Certified Professional in Utilization Review (CPUR) or Certified Case Manager (CCM) can improve job prospects, and strong analytical, communication, and organizational skills are essential for success in this role.
How much does a utilization review manager make?
A utilization review manager typically earns between $70,000 and $110,000 annually, depending on experience, location, and the size of the organization. They often require knowledge of healthcare policies, insurance processes, and may hold certifications such as URAC or CCM.
DIR - UTILIZATION REVIEW / MGMT
Jacksonville, FL • On-site
UHS
• Health Care and Social Assistance • 10K+ employees10,000+ employees
Full-time
Re-posted 4 days ago
Universal Health Services rating
6.8
Based on 255 frontline employees who took The Breakroom Quiz
Job description
Responsibilities
The Utilization Review Director is responsible for directing and overseeing the Utilization Management Department. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organization, external reviewers, and other payers.
Directly supervises a minimum of 5 staff. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems
Must be a Registered Nurse, and/or have a Bachelor's Degree in Social Work or Psychology or equivalent education and experience in Utilization Review/ Management. Has knowledge of regulatory and reimbursement requirements. Able to monitor and evaluate records for quality and appropriateness of care. Able to work independently and collegially with all clinical disciplines and staff within the hospital. Demonstrates leadership ability, good communication skills, ability to delegate and supervise.
Ability to read, analyze, and interpret common scientific and technical journals, financial reports and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.
Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
While performing the duties of this job, the employee is regularly required to stand, walk, and site; use hands to finger, handle, or feel, reach with hands and arms, stoop, kneel, crouch, or crawl.
The employee must regularly lift and/or move up to 25 pounds, and occasionally up to 75 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.
Qualifications
One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 300 corporation, annual revenues were $15.8 billion in 2024. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies.
Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
The Utilization Review Director is responsible for directing and overseeing the Utilization Management Department. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organization, external reviewers, and other payers.
Directly supervises a minimum of 5 staff. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems
Must be a Registered Nurse, and/or have a Bachelor's Degree in Social Work or Psychology or equivalent education and experience in Utilization Review/ Management. Has knowledge of regulatory and reimbursement requirements. Able to monitor and evaluate records for quality and appropriateness of care. Able to work independently and collegially with all clinical disciplines and staff within the hospital. Demonstrates leadership ability, good communication skills, ability to delegate and supervise.
Ability to read, analyze, and interpret common scientific and technical journals, financial reports and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.
Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
While performing the duties of this job, the employee is regularly required to stand, walk, and site; use hands to finger, handle, or feel, reach with hands and arms, stoop, kneel, crouch, or crawl.
The employee must regularly lift and/or move up to 25 pounds, and occasionally up to 75 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.
Qualifications
One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 300 corporation, annual revenues were $15.8 billion in 2024. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies.
Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
What Universal Health Services employees say
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About Universal Health Services
Sourced by ZipRecruiter
Universal Health Services (UHS) is a major player in the healthcare industry, based in King of Prussia, Pennsylvania, U.S. Founded in 1978, UHS offers hospital and healthcare services. Their diverse services range from acute care hospitals, behavioral health facilities and ambulatory centers nationwide. The company's mission of enhancing the health and well-being of their patients is reflected in their commitment to 'Helping Individuals Live Longer, Healthier and Happier Lives'. Universal Health Services' consistent growth and success in their industry have been recognized on numerous occasions, including being ranked amongst the Fortune 500 list of largest companies.
Industry
Health care and social assistance
Company size
10,000+ Employees
Headquarters location
King of Prussia, PA, US