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Utilization Review Specialist Jobs (NOW HIRING)

Nationwide Children's Hospital

Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines. * Communicates with healthcare teams and third ...

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Utilization Review Specialist information

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$15

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How much do utilization review specialist jobs pay per hour?

As of Aug 8, 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 Senior

BayCare Health System

Tampa, FL • On-site

Other

Retirement

Re-posted 22 days ago

BayCare Health System rating

7.5

Company rating: 7.5 out of 10

Based on 398 frontline employees who took The Breakroom Quiz

232nd of 887 rated healthcare providers

Job description

At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence.
The Utilization Review Specialist Senior responsibilities include:
  • Functions as the primary liaison between the funding agents and all other related parties to ensure appropriate level of care through comprehensive concurrent review for medical necessity of outpatient observation and inpatient stays and the utilization of ancillary services
  • Perform other duties as assigned by the supervisor including but not limited to processing concurrent denials.
  • Preferred experience includes Critical Care or Emergency Nursing RN.

Position details:
  • Location: Hybrid - St Josephs Hospital/Tampa, FL
  • Status: PRN, As Needed
  • Schedule: Days vary
  • Weekend Requirement: Strongly prefer availability for every other weekend
  • On Call: No

Certifications and Licensures:
  • Required RN (Registered Nurse)
  • Preferred ACM (Case Management)
  • Preferred CCM (Case Manager)

Education:
  • Required Associates in Nursing or
  • Required Bachelors in Nursing
  • Preferred Masters in Nursing or Business

Experience:
  • Required 2 years in Utilization Review or
  • Required 2 years in Case Management or
  • Required 3 years Registered Nurse
  • Preferred experience in Critical Care or Emergency Service

Benefits:
  • Tuition reimbursement
  • 401k match and additional yearly contribution
  • Community discounts and more

Equal Opportunity Employer Veterans/Disabled

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