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Utilization Review Specialist Jobs (NOW HIRING)

PARKSIDE INC

Utilization Review Specialist

Tulsa, OK · On-site

The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to limit possible recoupment from third party pay sources including Medicare, Medicaid, HMO or private ...

Banyan

Utilization Review Specialist

Pompano Beach, FL · On-site

$50K - $65K/yr

Utilization Review Specialist | Remote | Full-Time $50,000 - $65,000 Annually | Weekdays (Weekend Availability as Needed) Banyan Treatment Centers is seeking an experienced and detail-driven ...

Umpqua Health

Utilization Review Specialist

Winston, OR · On-site

$41K - $47K/yr

Utilization Review Specialist HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470 EMPLOYMENT TYPE- Full-Time, Exempt About Umpqua Health At Umpqua Health, we're more than a ...

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Utilization Review Specialist information

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How much do utilization review specialist jobs pay per hour?

As of Aug 6, 2026, the average hourly pay for utilization review specialist in the United States is $31.94, according to ZipRecruiter salary data. Most workers in this role earn between $22.36 and $40.62 per hour, depending on experience, location, and employer.

How does a utilization review specialist typically interact with healthcare providers and insurance companies?

Utilization Review Specialists serve as a key liaison between healthcare providers and insurance companies, reviewing patient records to ensure medical necessity and compliance with coverage guidelines. They frequently communicate with physicians and clinical staff to clarify documentation or treatment plans, as well as with insurance representatives to justify or appeal coverage decisions. This collaborative environment requires strong communication skills and a thorough understanding of medical protocols and payer requirements, making teamwork and attention to detail essential aspects of the role.

What is a utilization review specialist?

Utilization review specialists assess plans for patient care and determine what treatment is appropriate and most cost-effective. They investigate disputed medical claims, coordinate utilization training for the medical staff, analyze electronic medical records, and inform medical staff whether a medical claim is denied, approved, under review, or under appeal. In many cases, the utilization review specialist serves as an advocate for quality patient care, cost reduction, and hospital quality standards.

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

To thrive as a Utilization Review Specialist, you need a background in healthcare, strong analytical abilities, and typically a degree in nursing, social work, or a related field, often with relevant licensure. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance and regulatory guidelines are essential. Excellent communication, critical thinking, and attention to detail are crucial soft skills for collaborating with providers and advocating for appropriate patient care. These competencies ensure accurate assessments, regulatory compliance, and optimal resource utilization in healthcare settings.

What is the difference between Utilization Review Specialist vs Claims Reviewer?

AspectUtilization Review SpecialistClaims Reviewer
CredentialsOften requires healthcare-related certifications (e.g., RN, CPC)Typically requires insurance or billing certifications
Work EnvironmentHealthcare settings, insurance companies, hospitalsInsurance companies, healthcare payers, third-party administrators
Job FocusAssess medical necessity and appropriateness of servicesReview insurance claims for accuracy and coverage

While both roles involve reviewing healthcare-related information, the Utilization Review Specialist primarily evaluates the medical necessity of treatments, whereas the Claims Reviewer focuses on verifying insurance claims for correctness and coverage. Both positions require knowledge of healthcare and insurance processes but serve different functions within the healthcare and insurance industries.

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Utilization Review Specialist jobs near you
Infographic showing various Utilization Review Specialist job openings in the United States as of August 2026, with employment types broken down into 100% Full Time. Highlights an 89% In-person, and 11% Remote job distribution, with an average salary of $66,436 per year, or $31.9 per hour.

Utilization Review Specialist

Medical Center Hospital

Odessa, TX • On-site

Full-time

Re-posted 23 days ago

Medical Center Health System rating

8.4

Company rating: 8.4 out of 10

Based on 33 frontline employees who took The Breakroom Quiz

25th of 887 rated healthcare providers

Job description

Position Summary:

The Utilization Review Specialist/Outcomes Specialist conducts concurrent and retrospective review functions in support of the hospital Utilization Review Program and makes appropriate referrals to designated Physician Advisors.

Qualifications:

A. Education:

Holds a current Texas license as a Registered Nurse OR a current Texas Licensed Vocational Nurse.

B. Training and Experience:

Three years of clinical nursing experience in a general medical/surgical setting or appropriate specialty area; at least one year in an acute care setting.

C. Job Knowledge:

Excellent verbal and written skills, well-rounded critical thinking skills, self-motivated, flexible, and goal-oriented. Ability to tolerate frequent interruptions and demanding workload.

VI. Unusual Physical Demands and Working Conditions:

Must be able to work long hours on occasion. Potential for some stress in meeting deadlines.

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