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Utilization Review Specialist Jobs (NOW HIRING)

RECAP INC

Utilization Review Specialist

Middletown, NY

$27 - $34/hr

As a Utilization Review Specialist, you will play a vital role in ensuring that clinical services are medically necessary, appropriately authorized, and compliant with all regulatory and payer ...

Socket.dev

Utilization Review Specialist

Indianapolis, IN · On-site

$60 - $80/hr

The Utilization Review Specialist serves as a key resource in minimizing prescription delays, supporting reimbursement efforts, optimizing patient outcomes, and minimizing claim denials. The ...

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TEKsystems

Utilization Review Specialist

Addison, TX · On-site

$70K - $100K/yr

Description Methodist Surgery Center, part of the Surgery Partners network, is seeking an experienced Utilization Review Specialist to join its team in Addison, Texas. This position is ideal for ...

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How much do utilization review specialist jobs pay per hour?

As of Sep 2, 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.

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?

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.

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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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 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, and 3% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution, with an average salary of $66,436 per year, or $31.9 per hour.

Utilization Review Specialist

RECAP INC

Middletown, NY

$27 - $34/hr

Full-time

Posted 5 days ago

Job description

Join a mission-driven organization dedicated to providing high-quality, person-centered care for individuals with substance use disorders. The agency operates two New York State OASAS-certified programs: a Part 820 Residential Reintegration Program and a Part 822 Outpatient Rehabilitation Program. As a Utilization Review Specialist, you will play a vital role in ensuring that clinical services are medically necessary, appropriately authorized, and compliant with all regulatory and payer requirements. This position offers the opportunity to collaborate with a multidisciplinary team, support quality improvement initiatives, and help maximize access to care for those in need.

Responsibilities
  • Obtain initial, concurrent, and continued stay authorizations from Medicaid Managed Care Organizations and commercial insurance plans.
  • Conduct comprehensive reviews of clinical documentation to ensure compliance with medical necessity, ASAM Criteria, and OASAS regulations.
  • Monitor authorization expiration dates and ensure uninterrupted coverage for clients.
  • Coordinate peer-to-peer reviews, reconsiderations, and appeals for denied or reduced services.
  • Maintain accurate authorization tracking logs and document all utilization review activities in the electronic health record.
  • Collaborate with clinical, medical, and administrative staff to ensure treatment plans and documentation support payer requirements and regulatory standards.
  • Assist clinicians in strengthening documentation and provide feedback on best practices.
  • Participate in internal quality assurance, utilization review, and quality improvement initiatives.
  • Support revenue cycle management by ensuring services are properly authorized and investigating discrepancies affecting reimbursement.
  • Attend multidisciplinary team meetings and serve as a resource on payer requirements and medical necessity criteria.
  • Assist with regulatory readiness, including preparation for OASAS certification reviews and audits.
  • Maintain confidentiality in accordance with HIPAA and 42 CFR Part 2.
  • Perform additional duties as assigned.
Qualifications
  • Bachelor's degree in Social Work, Psychology, Human Services, Nursing, or a related behavioral health field required; Master's degree preferred.
  • One of the following credentials required: LMSW, LCSW, LMHC, CASAC, CASAC-AC, CASAC-MC, RN, or other qualified health professional recognized by NYS OASAS.
  • Minimum of three years of experience in behavioral health or substance use disorder treatment.
  • At least two years of experience in utilization review, case management, quality improvement, or managed care preferred.
  • Experience working in an OASAS-certified program strongly preferred.
  • Experience with Medicaid Managed Care and commercial insurance plans required.
  • Knowledge of ASAM Criteria required.
  • Strong clinical assessment and documentation review skills.
  • Excellent written and verbal communication skills.
  • Ability to analyze clinical documentation for regulatory compliance.
  • Strong organizational and time management skills, with the ability to prioritize multiple deadlines.
  • Proficiency in electronic health records and Microsoft Office applications.
  • Ability to sit for prolonged periods and use computers and office equipment; occasional lifting up to 20 pounds.
  • Ability to travel between agency locations as required.