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Utilization Review Jobs in Puerto Rico (NOW HIRING)

APS Health Care PR

PR · On-site

The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual ...

OncoHealth

Case Review Representative

Guaynabo, PR · On-site +1

$13 - $15/hr

About the Role The Case Review Representative serves as a one-stop shop and intake of all calls ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

OncoHealth

Case Review Representative

Guaynabo, PR · On-site

About the Role The Case Review Representative serves as a one-stop shop and intake of all calls ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

Encompass Health

Case Manager

Manati, PR

$17 - $21.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

Encompass Health

Case Manager

Manati, PR

$17 - $21.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

OncoHealth

Case Review Specialist - PR

Guaynabo, PR · On-site

About the Role The Case Review Specialist ensures that case documentation is provided by the ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

OncoHealth

Case Review Specialist - PR

Guaynabo, PR · On-site +1

About the Role The Case Review Specialist ensures that case documentation is provided by the ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...

UHS

PR · On-site

Provide backup to Utilization Review Department out of business hours including document in the appropriate platform services request, provide information of service request status, provide ...

Cooper Companies

Planner

Juana Diaz, PR · On-site

Day to day capacity utilization Supply Chain advice * Assuring Compliance with Laws & Regulations ... Reviewing shortage materials with suppliers * Material procurement packaging design * Providing ...

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Utilization Review information

What jobs make $3,000 a day?

High-paying jobs that can reach $3,000 a day include specialized roles such as senior physicians, anesthesiologists, or surgeons, often requiring advanced certifications and extensive experience. Certain executive positions, like CEOs or investment bankers, may also earn this level of daily income, especially through bonuses or profit sharing. These roles typically involve high responsibility, expertise, and demanding schedules.

What jobs pay 4000 a week without a degree?

Utilization Review specialists typically do not earn $4,000 per week without a degree; most roles in this field require healthcare-related certifications or experience. High-paying jobs that can reach this level without a degree include certain sales positions, real estate brokers, or specialized trades like commercial pilots or skilled trades, which often rely on experience, licensing, or certifications rather than formal degrees. These roles may involve commission, bonuses, or overtime to achieve such weekly earnings.

What does a typical day look like for someone working in Utilization Review?

A typical day in Utilization Review involves reviewing patient medical records, evaluating the necessity and appropriateness of proposed treatments or services, and documenting recommendations based on clinical criteria and insurance policies. Utilization Review specialists often collaborate closely with physicians, nurses, and insurance representatives to gather additional information and clarify cases. While much of the role is desk-based and may include remote work options, it requires regular communication with both clinical and administrative teams. This position offers variety and challenge, as no two cases are exactly alike, and there are often opportunities to advance into supervisory or quality improvement roles within the department.

What skills do you need for utilization review?

Utilization review professionals need strong analytical skills to assess medical necessity and appropriateness of care, attention to detail, and knowledge of healthcare regulations and insurance policies. Good communication skills are essential for coordinating with healthcare providers and explaining decisions. Familiarity with electronic health records (EHR) systems and relevant certifications, such as Certified Professional in Healthcare Quality (CPHQ), can also be beneficial.

What is a Utilization Review job?

A Utilization Review (UR) job involves assessing the medical necessity, efficiency, and appropriateness of healthcare services. UR professionals, often nurses or healthcare specialists, review patient records, insurance claims, and treatment plans to ensure they meet industry standards and payer requirements. They work with healthcare providers, insurance companies, and regulatory agencies to optimize care while controlling costs. Their goal is to balance quality patient care with cost-effective resource utilization.

What are the key skills and qualifications needed to thrive in the Utilization Review position, and why are they important?

To thrive in Utilization Review, professionals typically need a background in nursing or healthcare, strong clinical assessment capabilities, and a thorough understanding of medical guidelines and insurance regulations. Familiarity with electronic medical records (EMR) systems and utilization management software, and often certification such as Certified Utilization Review Specialist (CURN), are important. Excellent critical thinking, attention to detail, and strong communication skills enable effective case evaluation and collaboration with healthcare teams. These skills and qualifications ensure objective, accurate decisions that support cost-effective, quality patient care within compliance standards.

How do I get into a utilization review?

To become a utilization review specialist, typically a healthcare professional such as a registered nurse, licensed social worker, or physician completes relevant education and gains experience in healthcare or insurance. Certification in utilization review or case management, such as the Certified Professional in Healthcare Quality (CPHQ), can improve job prospects. Strong analytical skills and knowledge of medical coding and insurance policies are also important.
What are the most commonly searched types of Utilization Review jobs in Puerto Rico? The most popular types of Utilization Review jobs in Puerto Rico are:
What are popular job titles related to Utilization Review jobs in Puerto Rico? For Utilization Review jobs in Puerto Rico, the most frequently searched job titles are:
What job categories do people searching Utilization Review jobs in Puerto Rico look for? The top searched job categories for Utilization Review jobs in Puerto Rico are:
Utilization Review jobs near you
Infographic showing various Utilization Review job openings in Puerto Rico as of July 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, and 3% Contract. Highlights an 91% Physical, 3% Hybrid, and 6% Remote job distribution.

Utilization Coordinator

San Juan Capestrano

San Juan, PR

Full-time

Posted 12 days ago

Job description

Overview

PURPOSE STATEMENT: 

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.  

Responsibilities

ESSENTIAL FUNCTIONS: 

  • Act as liaison between managed care organizations and the facility professional clinical staff. 
  • Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements. 
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.  
  • Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. 
  • Conduct quality reviews for medical necessity and services provided.   
  • Facilitate peer review calls between facility and external organizations.  
  • Initiate and complete the formal appeal process for denied admissions or continued stay.  
  • Assist the admissions department with pre-certifications of care.  
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates. 

OTHER FUNCTIONS:  

  • Perform other functions and tasks as assigned. 
Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

  • Required Education: High school diploma or equivalent. 
  • Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field. 
  • Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred 

LICENSES/DESIGNATIONS/CERTIFICATIONS:  

  • Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services. 
  • CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.   
  • First aid may be required based on state or facility requirements. 

 

ADDITIONAL REGULATORY REQUIREMENTS: 

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances  (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate. 

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.

Employment Type: FULL_TIME

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