Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal ... Minimum one year experience in a Utilization Management department in behavioral health or as a ...
Utilization Mgmt Clinical RN
Bellaire, TX · On-site
... telephonic and/or concurrent review of inpatient hospitalizations and extended courses of ... 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined ...
Utilization Mgmt Clinical RN
Bellaire, TX · On-site
... telephonic and/or concurrent review of inpatient hospitalizations and extended courses of ... 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined ...
Clinical Documentation Specialist RN
Houston, TX · On-site
$90 - $110/hr
Coding and utilization review experience preferred LICENSES AND CERTIFICATIONSRequired * RN - ... CCS - Certified Coding Specialist (AHIMA) KNOWLEDGE AND ABILITIES * Demonstrates the skills and ...
New
Clinical Documentation Specialist RN
Houston, TX · On-site
$90 - $110/hr
Coding and utilization review experience preferred LICENSES AND CERTIFICATIONSRequired * RN - ... CCS - Certified Coding Specialist (AHIMA) KNOWLEDGE AND ABILITIES * Demonstrates the skills and ...
New
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
Case Management Coordinator (69156)
Katy, TX · On-site
$55 - $75/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
Case Management Coordinator (69156)
Katy, TX · On-site
$55 - $75/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
Case Management Coordinator (69162)
Katy, TX · On-site
$60 - $90/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
Case Management Coordinator (69162)
Katy, TX · On-site
$60 - $90/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
RN Branch Manager - Home Health
Houston, TX · On-site
$90 - $120/hr
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
RN Branch Manager - Home Health
Houston, TX · On-site
$90 - $120/hr
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
Case Management Coordinator (69164)
Katy, TX · On-site
$55 - $75/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
Case Management Coordinator (69164)
Katy, TX · On-site
$55 - $75/hr
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... providers, specialists, home health agencies, and community resources, to ensure seamless ... coordination, utilization review, or population health management within a healthcare setting.
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
... Review Specialist) to ensure the medical records reflect compliance with medical necessity, homebound status, visit utilization, and documentation of individualized patient assessment and transition ...
Utilization Review Specialist information
See Spring, TX salary details
$13.90 - $16.98
14% of jobs
$19.52 is the 25th percentile. Wages below this are outliers.
$16.98 - $20.05
14% of jobs
$20.05 - $23.12
17% of jobs
The median wage is $24.81 / hr.
$23.12 - $26.20
11% of jobs
$26.20 - $29.27
8% of jobs
$29.27 - $32.34
6% of jobs
$34.64 is the 75th percentile. Wages above this are outliers.
$32.34 - $35.41
7% of jobs
$35.41 - $38.49
7% of jobs
$38.49 - $41.56
5% of jobs
$41.56 - $44.63
5% of jobs
$44.63 - $47.70
5% of jobs
$13
$28
$47
How much do utilization review specialist jobs pay per hour?
As of Sep 2, 2026, the average hourly pay for utilization review specialist in Spring, TX is $28.42, according to ZipRecruiter salary data. Most workers in this role earn between $19.90 and $36.15 per hour, depending on experience, location, and employer.
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.
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 the difference between Utilization Review Specialist vs Claims Reviewer?
| Aspect | Utilization Review Specialist | Claims Reviewer |
|---|---|---|
| Credentials | Often requires healthcare-related certifications (e.g., RN, CPC) | Typically requires insurance or billing certifications |
| Work Environment | Healthcare settings, insurance companies, hospitals | Insurance companies, healthcare payers, third-party administrators |
| Job Focus | Assess medical necessity and appropriateness of services | Review 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.
How much does a utilization review specialist make in California?
The average salary for a utilization review specialist in California ranges from $60,000 to $80,000 annually, depending on experience, certifications, and location. Salaries may also vary based on the employer and whether the role is full-time or part-time, with some positions offering additional benefits or bonuses.
Is utilization review a good job?
Utilization Review Specialists evaluate medical necessity and appropriateness of healthcare services, often working in healthcare or insurance settings. The role typically requires strong analytical skills, attention to detail, and knowledge of healthcare regulations, with opportunities for certification and career advancement. It can offer stable employment and a predictable schedule, but job satisfaction depends on individual preferences and work environment.
More about Utilization Review Specialist jobs
What are popular job titles related to Utilization Review Specialist jobs in Spring, TX?
For Utilization Review Specialist jobs in Spring, TX, the most frequently searched job titles are:
What job categories do people searching Utilization Review Specialist jobs in Spring, TX look for?
The top searched job categories for Utilization Review Specialist jobs in Spring, TX are:
What cities near Spring, TX are hiring for Utilization Review Specialist jobs?
Cities near Spring, TX with the most Utilization Review Specialist job openings:
Per diem
Retirement
Re-posted 9 days ago
Job description
Come join SUN Behavioral Houston, where our mission is to partner with communities to solve the unmet needs of those who suffer from mental illness and substance use disorders. We are a free-standing psychiatric hospital that operates 24/7 that provides a full continuum of specialized care, including inpatient and day hospital services, and offer specialized programs for children, adolescents and adults. As a member of SUN Behavorial's diverse team of professionals, you will be provided meaningful employment and a supportive culture. For more information, visit www.sunhouston.com.
Work Schedule: Variable, Monday - Friday (8a-5p)
Location: 7601 Fannin St, Houston, Texas. 77054
FTE: PRN, Non-Exempt
What We Offer:
Position Summary:
Responsible for the coordination of case management strategies pursuant to the Case Management process. Assists and coordinates care of the patient from pre-hospitalization through discharges. Responsible for assisting with authorization of admissions to hospital. Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal letters for insurance companies to ensure coverage for patient admissions. Conducts follow up calls with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department.
Position Requirements:
Position Responsibilities:
Clinical / Technical Skills (40% of performance review)
Safety (15% of performance review)
Teamwork (15% of performance review)
Integrity (15% of performance review)
Compassion (15% of performance review)
Work Schedule: Variable, Monday - Friday (8a-5p)
Location: 7601 Fannin St, Houston, Texas. 77054
FTE: PRN, Non-Exempt
What We Offer:
- 401(k) Plan with company match
- Employee Assistance Program (EAP)
- Employee Discount Savings Program
Position Summary:
Responsible for the coordination of case management strategies pursuant to the Case Management process. Assists and coordinates care of the patient from pre-hospitalization through discharges. Responsible for assisting with authorization of admissions to hospital. Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal letters for insurance companies to ensure coverage for patient admissions. Conducts follow up calls with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department.
Position Requirements:
- Required: High school diploma or GED. CPR and hospital-selected de-escalation technique certification.
- Required: Minimum one year of experience in a healthcare setting.
- Preferred: Current unencumbered LMSW/LPCa license in the state of employment, or Bachelors degree in a behavioral health field or business administration.
- Preferred: Minimum one year experience in a Utilization Management department in behavioral health or as a Mental Health Tech
- Maintains education and development appropriate for position.
- May substitute experience for education
- May substitute education for experience
Position Responsibilities:
Clinical / Technical Skills (40% of performance review)
- Provides thorough documentation and timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews and discharges; including case s with limited benefits, cases in peer review/denial and /or unplanned discharges
- Coordinates with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Document s and updates the denial log to reflect same.
- Consults Business Office and/or admission staff as needed to clarify data and ensure authorization processes are complete.
- Documents in HCS the results of admission and concurrent reviews.
- Stays informed about changes in Medicare and Medicaid.
- Ability to stage local laws, ordinances and practices governing involuntary hospitalization and ensure compliance with same.
- Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment.
- Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Oversees continuity of care for each level of care transition.
- Develops and maintains processes to minimize denials and communication of same to CFO and Business Office Director.
- Reports results of daily treatment team meetings all discharges and status of high-risk case such as limited benefits, peer reviews, denials or unplanned discharges.
- Timely retroactive reviews and appeals within current month
- Strong knowledge of external review organizations (i.e.: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
- Types and mails all correspondence in a timely manner.
- Answers the telephone in a polite manner, Communicates information to the appropriate staff.
- Interacts with patients/families in a professional manner. Provides explanations regarding statements, insurance coverage.
- Support discharge planning and utilization review when necessary
- Perform other duties as required
Safety (15% of performance review)
- Strives to create a safe, healing environment for patients and family members
- Follows all safety rules while on the job.
- Reports near misses, as well as errors and accidents promptly.
- Corrects minor safety hazards.
- Communicates with peers and management regarding any hazards identified in the workplace.
- Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
- Participates in quality projects, as assigned, and supports quality initiatives.
- Supports and maintains a culture of safety and quality.
Teamwork (15% of performance review)
- Works well with others in a spirit of teamwork and cooperation.
- Responds willingly to colleagues and serves as an active part of the hospital team.
- Builds collaborative relationships with patients, families, staff, and physicians.
- The ability to retrieve, communicate, and present data and information both verbally and in writing as required
- Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
- Demonstrates adequate skills in all forms of communication.
- Adheres to the Standards of Behavior
Integrity (15% of performance review)
- Strives to always do the right thing for the patient, coworkers, and the hospital
- Adheres to established standards, policies, procedures, protocols, and laws.
- Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
- Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
- Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership
- Exemplifies professionalism through good attendance and positive attitude, at all times.
- Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
- Ensures proper documentation in all position activities, following federal and state guidelines.
Compassion (15% of performance review)
- Demonstrates accountability for ensuring the highest quality patient care for patients.
- Willingness to be accepting of those in need, and to extend a helping hand
- Desire to go above and beyond for others
- Understanding and accepting of cultural diversity and differences
About SUN Behavioral Houston
Sourced by ZipRecruiter
Industry
Offices of mental health practitioners
Company size
51 - 200 Employees
Headquarters location
Houston, TX, US
Year founded
2015