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Utilization Review Specialist Jobs in Decatur, GA

Acadia Healthcare

Utilization Specialist

Riverdale, GA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...

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All JobsUtilization Review Specialist JobsUtilization Review Specialist Jobs in Decatur, GA

Utilization Review Specialist information

See Decatur, GA salary details

$15

$31

$52

How much do utilization review specialist jobs pay per hour?

As of Jul 18, 2026, the average hourly pay for utilization review specialist in Decatur, GA is $31.18, according to ZipRecruiter salary data. Most workers in this role earn between $21.83 and $39.66 per hour, depending on experience, location, and employer.

What jobs pay 4000 a week without a degree?

Utilization Review Specialists typically do not earn $4,000 weekly without a degree, as this role usually requires healthcare or insurance industry knowledge and certifications. High-paying jobs that can reach this level without a degree often include skilled trades like commercial driving, sales, or certain entrepreneurial ventures, but these are less common and may require experience or licensing. Most jobs paying $4,000 a week without a degree are in specialized fields or involve self-employment.

What is the most chill healthcare job?

A Utilization Review Specialist typically works in a healthcare setting reviewing medical cases to determine coverage and appropriateness of care. The role often involves standard office hours, minimal physical demands, and requires strong attention to detail, making it a relatively low-stress position compared to more clinical or emergency roles.

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.

Is utilization review a stressful job?

Utilization review specialists often work in fast-paced healthcare environments where accuracy and efficiency are important, which can contribute to job stress. The role involves reviewing medical cases and making determinations that impact patient care, requiring attention to detail and adherence to policies, but stress levels vary depending on workload, support, and individual coping skills.

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 is a utilization review specialist?

A utilization review specialist evaluates medical services to determine their necessity, appropriateness, and efficiency for insurance companies or healthcare providers. They review patient records, ensure compliance with guidelines, and often work with healthcare professionals to approve or deny claims, typically requiring knowledge of medical coding and insurance policies.

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.

What are Utilization Review Specialists?

Utilization Review Specialists are healthcare professionals who assess the necessity, appropriateness, and efficiency of medical services and treatments provided to patients. They review patient records, treatment plans, and insurance information to ensure that care meets established guidelines and is medically necessary. Their work helps manage healthcare costs, prevent unnecessary procedures, and ensure compliance with regulations and insurance policies. Utilization Review Specialists often work for hospitals, insurance companies, or other healthcare organizations.
More about Utilization Review Specialist jobs
What are popular job titles related to Utilization Review Specialist jobs in Decatur, GA? For Utilization Review Specialist jobs in Decatur, GA, the most frequently searched job titles are:
What job categories do people searching Utilization Review Specialist jobs in Decatur, GA look for? The top searched job categories for Utilization Review Specialist jobs in Decatur, GA are:
Utilization Review Specialist jobs near you
Infographic showing various Utilization Review Specialist job openings in Decatur, GA as of July 2026, with employment types broken down into 1% As Needed, 76% Full Time, 17% Part Time, 2% Temporary, and 4% Contract. Highlights an 89% Physical, 2% Hybrid, and 9% Remote job distribution, with an average salary of $64,864 per year, or $31.2 per hour.
Utilization/Clinical Review RN -PRN

Utilization/Clinical Review RN -PRN

Children's Healthcare of Atlanta

Atlanta, GA • On-site

Part-time

Posted 23 hours ago

Children's Healthcare Of Atlanta rating

7.5

Company rating: 7.5 out of 10

Based on 127 frontline employees who took The Breakroom Quiz

231st of 886 rated healthcare providers

Job description

Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs).
Work Shift
Variable
Work Day(s)
Variable
Shift Start Time
6:00 AM
Shift End Time
5:00 PM
Worker Sub-Type
PRN
Children's is one of the nation's leading children's hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We're committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children's.
Job Description
Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of all applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated. Maintains necessary documentation and communication with internal and external customers.
This role is PRN and requires (6) 8-hour days per month with 1 day being on the weekend. We'll be open to offering more if possible. Some Holidays are required as well.
Training/Orientation will be 3 days/week (8-hour days) for 8-10 weeks. Onsite Orientation is needed 3-4 days for first week.
This role will be remote BUT regular meetings/trainings require being onsite at the Support Center in Atlanta GA.
Experience
  • 3 years of experience in a healthcare setting; pediatrics preferred

Preferred Qualifications
  • Bachelor of Science in Nursing
  • Previous experience with MCG and/or InterQual systems
  • 2 years of experience in hospital or insurance related utilization review highly preferred

Education
  • Graduation from an accredited school of nursing

Certification Summary
  • Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact

Knowledge, Skills, and Abilities
  • Working knowledge of financial aspects of third-party payors and reimbursement
  • Effective decision-making/problem-solving skills
  • Demonstration of creativity in problem-solving
  • Must possess above-average computer skills
  • Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment

Job Responsibilities
  • Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan.
  • Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day.
  • Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues.
  • Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria.
  • Ensures all pertinent information is documented into various systems for utilization review process.
  • Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems.
  • Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary.
  • Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process.
  • Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning.
  • Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing.
  • Attends all required onsite, telephonic, and mandatory department meetings.
  • Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members.

Children's Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law.
Primary Location Address
1575 Northeast Expy NE
Job Family
Nursing-Non Bedside

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