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Utilization Review Physician Jobs (NOW HIRING)

Netsmart

Utilization Review Nurse

Utilization Review Nurse Responsible for utilization review work for emergency admissions and ... Participate in telephonic discussions with emergency department physicians relative to ...

TEKsystems

Utilization Review Specialist

Addison, TX

$70K - $100K/yr

Utilization review experience Additional Skills & Qualifications * Perform utilization review ... Collaborate with physicians, case management teams, and payers to support authorization and ...

New

UofL Health

RN Utilization Review

Louisville, KY · On-site

With more than 12,000 team members-physicians, surgeons, nurses, pharmacists and other highly ... Position Summary and Purpose The Utilization Review RN performs activities which support the ...

UHS

Utilization Review Clinician

Augusta, GA

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... with physicians, therapist, nurses and pertinent staff on gathering the necessary data to ... utilization review. CERTIFICATIONS, LICENSES, REGISTRATION LMHC, LMFT, LAPC, LPC, LMSW, LCSW, LPN ...

UHS

Utilization Review Clinician

Augusta, GA · On-site

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... with physicians, therapist, nurses and pertinent staff on gathering the necessary data to ... utilization review. CERTIFICATIONS, LICENSES, REGISTRATION LMHC, LMFT, LAPC, LPC, LMSW, LCSW, LPN ...

PARKSIDE INC

Utilization Review Specialist

Tulsa, OK · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

For over 65 years, Parkside's physicians, therapists, and staff have provided state of the art, ... The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to ...

TEKsystems

Utilization Review Specialist

Addison, TX

$70K - $100K/yr

Utilization review experience Additional Skills & Qualifications * Perform utilization review ... Collaborate with physicians, case management teams, and payers to support authorization and ...

New

University of Utah

Utilization Review Nurse

Alerts and discusses with physician/provider and case manager/discharge planner when patient no ... One year Utilization Review or Case Management experience. Licenses Required * Current license to ...

Uoflhealth

RN Utilization Review

Louisville, KY · On-site

With more than 12,000 team members-physicians, surgeons, nurses, pharmacists and other highly ... Position Summary and Purpose The Utilization Review RN performs activities which support the ...

Lifepoint Health

Utilization Review Specialist

Tucson, AZ · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

As a Utilization Review Specialistjoining our team, you're embracing a vital mission dedicated to ... Communicates with physicians to schedule peer-to-peer reviews. * Accurately reports denials. About ...

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How much do utilization review physician jobs pay per hour?

As of Aug 15, 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.

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.

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.
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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, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Nurse

Netsmart

Remote

Other

Posted 4 days ago

Netsmart rating

8.3

Company rating: 8.3 out of 10

Based on 8 frontline employees who took The Breakroom Quiz

45th of 224 rated it services

Job description

Utilization Review Nurse

Responsible for utilization review work for emergency admissions and continued stay reviews. Responsibilities include:

  • Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria
  • Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources
  • Participate in telephonic discussions with emergency department physicians relative to documentation and admission status
  • Enter clinical review information into system for transmission to insurance companies for authorization
  • Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

Qualifications required:

  • Current and unrestricted RN license
  • At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
  • At least 2 years utilization management experience in acute admission and concurrent reviews
  • Intermediate level experience with InterQual and/or MCG criteria within the last two years
  • Proficiency in medical record review in an electronic medical record (EMR)
  • Experience in Microsoft Suite including Office and basic Excel
  • Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs
  • Passing score(s) on job-related pre-employment assessment(s)

Preferred:

  • At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
  • At least 3 years utilization management experience within the hospital setting
  • Bachelor's of Science in Nursing (BSN)
  • Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC)

Expectations:

  • Comfortable with remote work arrangements and virtual collaboration tools
  • Physical demands include extended periods of sitting, computer use, and telephone communication

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart's sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart's third party screening provider.

If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled.

All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

Netsmart's Job Applicant Privacy Notice may be found here.

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