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Utilization Review Physician Jobs (NOW HIRING)

Orison

RN - Utilization Review

Elmhurst, NY · On-site

Communicate with physicians and other healthcare providers regarding clinical information and ... Non-acute utilization review. Skills: RN,REGISTERED NURSE

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How much do utilization review physician jobs pay per hour?

As of Sep 7, 2026, the average hourly pay for utilization review physician in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

What is a utilization review physician?

A Utilization Review Physician is a medical doctor who evaluates the necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities. They review patient medical records, treatment plans, and insurance policies to ensure that the care provided meets established guidelines and is medically necessary. Their work helps healthcare organizations and insurance companies manage costs while ensuring patients receive proper care. Utilization Review Physicians often collaborate with healthcare providers and insurance representatives to make coverage and care decisions. They play a critical role in maintaining quality standards in healthcare delivery.

What does a utilization review physician do?

A utilization review physician depresses healthcare costs and prevents medical resource overuse. You typically work with health insurance companies to review claims or pre-authorization requests submitted by other doctors. Your other responsibilities include informing doctors of the reasons for coverage refusal, whether it be for treatment, medication, or another request. You write medical review reports, ensure requests fit the patient’s coverage or insurance plan, ensure medical necessity for hospitalization incidents, perform pharmaceutical reviews, schedule independent medical examinations, and make sure that prescribed drugs are truly necessary. You may also work for a disability insurance company to determine the qualifications regarding payouts.

How does a utilization review physician typically interact with other healthcare professionals during the review process?

Utilization Review Physicians regularly collaborate with case managers, nurses, attending physicians, and insurance representatives to assess the medical necessity and appropriateness of patient care. They review clinical documentation, provide feedback, and may request additional information to ensure that care meets established guidelines. Clear communication and a collaborative approach are essential, as the role often involves discussing complex cases and educating clinical staff on best practices and compliance requirements.

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

To thrive as a Utilization Review Physician, you need a medical degree (MD or DO), board certification in a clinical specialty, and in-depth knowledge of evidence-based medicine and healthcare regulations. Familiarity with utilization management software, electronic health records (EHRs), and compliance standards such as CMS guidelines is crucial. Strong analytical skills, attention to detail, and effective communication are essential soft skills for reviewing cases and collaborating with healthcare teams. These competencies ensure accurate assessments, cost-effective care, and adherence to regulatory requirements in the healthcare system.

What is the difference between Utilization Review Physician vs Medical Director?

AspectUtilization Review PhysicianMedical Director
CredentialsMedical degree, medical license, board certification in relevant specialtyMedical degree, medical license, often additional leadership or management certifications
Work EnvironmentHospitals, insurance companies, healthcare organizations, primarily review and evaluate patient casesHealthcare organizations, insurance companies, overseeing clinical operations and policy development
Employer & Industry UsageUsed in insurance, managed care, and healthcare facilities for utilization reviewUsed in healthcare organizations and insurance companies for leadership and policy oversight

The Utilization Review Physician focuses on evaluating patient cases to determine appropriate care and resource use, while the Medical Director oversees clinical policies and manages healthcare operations. Both roles require medical credentials, but the Medical Director often has additional leadership responsibilities.

Is utilization review a good job?

Utilization review physicians evaluate medical necessity and appropriateness of healthcare services, often working in insurance companies or healthcare organizations. The role typically requires strong clinical knowledge, attention to detail, and familiarity with medical guidelines, with schedules that can be regular or flexible depending on the employer. It can offer a stable career with opportunities for advancement and work-life balance, but job satisfaction depends on individual preferences and work environment.
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Utilization Review Physician jobs near you
Infographic showing various Utilization Review Physician job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

RN - Utilization Review

Orison Solutions

New York, NY

$65 - $70/hr

Contractor

Posted 4 days ago

Job description

Job Summary


We are seeking an experienced Registered Nurse (RN) - Utilization Review to evaluate the medical necessity, appropriateness, and level of care for patients. The RN will review clinical documentation, apply established medical guidelines, and collaborate with physicians, case managers, health plans, and other healthcare professionals to ensure appropriate utilization of healthcare services.

Key Responsibilities

  • Conduct prospective, concurrent, and retrospective utilization reviews of patient records.
  • Evaluate medical necessity and appropriateness of admissions, continued stays, procedures, and levels of care.
  • Review clinical documentation and medical records to determine whether services meet established criteria.
  • Apply evidence-based guidelines such as InterQual, MCG, CMS, and payer-specific criteria, as applicable.
  • Communicate with physicians and other healthcare providers regarding clinical information and utilization decisions.
  • Identify opportunities for appropriate resource utilization and cost-effective care.
  • Collaborate with Case Management, Quality Management, Medical Directors, and insurance companies.
  • Prepare and maintain accurate documentation of utilization review activities.
  • Escalate cases to the appropriate physician advisor or Medical Director when criteria are not met or additional clinical review is required.
  • Assist with authorization requests, denials, appeals, and reconsiderations when applicable.
  • Ensure compliance with applicable healthcare regulations, organizational policies, and payer requirements.
  • Maintain confidentiality of patient information in accordance with HIPAA regulations.
Required Certifications & Licensure
  • New York State RN License.
  • Primary Source Verification.
  • AHA BLS.
Required Skills & Experience
  • One (1) year of non-acute utilization review experience.
Preferred Skills & Experience
  • RN experience.
Skills
  • Non-acute utilization review.