The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client ... Review utilization trends and recommend process improvements or efficiencies Documentation ...
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client ... Review utilization trends and recommend process improvements or efficiencies Documentation ...
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client ... Review utilization trends and recommend process improvements or efficiencies Documentation ...
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client ... Review utilization trends and recommend process improvements or efficiencies Documentation ...
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 ...
... 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 ...
... 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 ...
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
Katy, TX · On-site
$32 - $43/hr
Coding and utilization review experience preferred LICENSES AND CERTIFICATIONS Required * RN - ... CCS - Certified Coding Specialist (AHIMA) SKILLS AND ABILITIES * Demonstrates the skills and ...
Clinical Documentation Specialist RN
Katy, TX · On-site
$32 - $43/hr
Coding and utilization review experience preferred LICENSES AND CERTIFICATIONS Required * RN - ... CCS - Certified Coding Specialist (AHIMA) SKILLS AND ABILITIES * Demonstrates the skills and ...
... 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 ...
Clinical Branch Manager RN - Home Health
Houston, TX · On-site
$110 - $140/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 ...
Clinical Branch Manager RN - Home Health
Houston, TX · On-site
$110 - $140/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 ...
... 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 ...
Nurse Case Manager
Houston, TX · On-site
Essential Duties and Responsibilities Case Management & Utilization Review * Provide telephonic ... Collaborate with Referral Management and Placement Specialists to ensure all coverage and ...
Nurse Case Manager
Houston, TX · On-site
Essential Duties and Responsibilities Case Management & Utilization Review * Provide telephonic ... Collaborate with Referral Management and Placement Specialists to ensure all coverage and ...
Nurse Case Manager
Houston, TX · On-site
Essential Duties and Responsibilities Case Management & Utilization Review * Provide telephonic ... Collaborate with Referral Management and Placement Specialists to ensure all coverage and ...
Nurse Case Manager
Houston, TX · On-site
Essential Duties and Responsibilities Case Management & Utilization Review * Provide telephonic ... Collaborate with Referral Management and Placement Specialists to ensure all coverage and ...
Build strong relationship with specialist, hospitalist, SNF and other providers to form a narrow ... Develop, implement and monitor the outcomes of utilization review and disease management programs ...
Build strong relationship with specialist, hospitalist, SNF and other providers to form a narrow ... Develop, implement and monitor the outcomes of utilization review and disease management programs ...
About the Role As an Appeals and Grievances Specialist, you'll own the end-to-end handling of ... utilization review, or a related health insurance operations role * Working knowledge of health ...
Quick apply
About the Role As an Appeals and Grievances Specialist, you'll own the end-to-end handling of ... utilization review, or a related health insurance operations role * Working knowledge of health ...
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 Aug 21, 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.
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Cities near Spring, TX with the most Utilization Review Specialist job openings:
Full-time, Contractor
Medical, Retirement, PTO
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Job description
At EMC Behavioral Health, we believe mental health begins with passionate care, intentional connection and the power of evidence-based practice. Guided by our mission to deliver the highest quality, client-centered care and our vision to equip individuals with innovative tools for lasting mental wellness, we serve as a trusted partner to clients, families, and communities seeking meaningful change. If your driven by purpose, energized by advocacy, and committed to ensuring that care is both clinically sound and deeply human, you will find your calling here at EMC.
Position Summary:
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client receives timely, appropriate, and medically necessary care. This role seamlessly integrates care coordination, clinical assessment, and utilization management to support strong recovery outcomes, uphold regulatory and payer requirements, and strengthen overall operational efficiency. We're seeking a clinically grounded professional with sharp analytical insight, exceptional communication skills, and a genuine commitment to serving diverse populations within a dynamic behavioral health setting.
Position Summary:
The Utilization Specialist is a key driver of EMC's clinical excellence, ensuring each client receives timely, appropriate, and medically necessary care. This role seamlessly integrates care coordination, clinical assessment, and utilization management to support strong recovery outcomes, uphold regulatory and payer requirements, and strengthen overall operational efficiency. We're seeking a clinically grounded professional with sharp analytical insight, exceptional communication skills, and a genuine commitment to serving diverse populations within a dynamic behavioral health setting.
What You'll Do:
In this high-impact role, you will help ensure clients receive the right care at the right time while supporting EMC's commitment to clinical excellence. Your responsibilities will include:
Care Coordination & Client Support:
- Coordinate appointments, therapy sessions, referrals, and supportive services
- Monitor client progress, medication adherence, and engagement in programming
- Partner with families, caregivers, and interdisciplinary teams to ensure continuity of care
- Conduct comprehensive initial and ongoing assessments
- Support clients with the individualized recovery plans and evidence-based coping strategies
- Serve as an internal resource on medical necessity, utilization workflows, and clinical best practices
- Lead prior authorizations, concurrent reviews, and discharge planning
- Ensure full compliance with payer guidelines, authorization limits, Medicaid/Medicare rules, and regulatory requirements
- Coach and train team members on documentation, compliance standards, and evolving regulations
- Review utilization trends and recommend process improvements or efficiencies
- Maintain accurate, timely documentation in the EHR and complete required assessments (CANS/ANSA)
- Prepare and submit monthly utilization and outcomes reports
- Participate in monthly UM meetings, audits, and continuous quality improvement initiatives
- Consistently uphold HIPAA and all state/federal behavioral health regulations
- Respond to call-outs, client emergencies and inquiries in alignment with protocols, including occasional after-hours support
- Support clinic outreach through community engagement, referral coordination, and collaboration with external partners
- Perform other duties as assigned
Minimum Qualifications:
- Bachelor’s degree in psychology, sociology, criminal justice, education or other related field (Master’s degree preferred)
- Active QMHP certification and HIPAA training
- CANS/ANSA certification (or willing to obtain)
- At least one year experience in behavioral health, case management or a clinical support role (2-3 years in a utilization management role preferred)
- Strong understanding of managed care, medical necessity criteria, and Medicaid authorizations
- Excellent documentation, assessment and critical-thinking skills
- Ability to collaborate effectively across clinical and administrative teams
Who Thrives in This Role:
You'll be a strong fit for EMC if you are:
- Mission-driven and committed to compassionate, high-quality care
- A confident communicator who builds rapport easily
- Detail-oriented, organized, and comfortable balancing multiple priorities
- Skilled at blending clinical judgment and operational decision-making
- Dedicated to ethical practice and ongoing professional development
- Make a meaningful difference in clients' lives every day
- Join a collaborative, supportive clinical team
- Access opportunities for professional growth, mentorship, and certification
- Be a part of a mission-driven organization that truly values quality, compassion, and innovation
- Contract to Hire
- This position begins as a full-time contract role through our company. Based on performance, business needs, and mutual fit, the role is intended to convert into a permanent, full-time position with comprehensive benefits.
- Monday-Friday with limited on-call responsibilities
- Hybrid clinical/administrative position in an outpatient behavioral health setting
- 2 days onsite in our Northwest Houston office, Tuesdays and Thursdays
- Requires regular use of EHR systems, reporting tools, and standard office equipment
- Group Health insurance options for full time employees, both employee and employer paid
- Paid Time Off
- Retirement Savings
Equal Opportunity Employer:
EMC Behavioral Health is an Equal Opportunity Employer and is committed to fostering a diverse, inclusive, and equitable work environment. We welcome applicants of all backgrounds, identities, and experiences.