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Utilization Review Jobs in Puerto Rico (NOW HIRING)

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 · On-site

$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 · On-site

$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

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 ...

UHS

PR

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 ...

Jj

Process Engineer

Manati, PR · On-site

... utilization of best process. Performs duties encompassing all process transfers and other projects ... Defines, analyzes, reviews and evaluates problems for prompt solutions. * Determines, adapts, and ...

Johnson & Johnson

Process Engineer

Manati, PR · On-site

... utilization of best process. Performs duties encompassing all process transfers and other projects ... Defines, analyzes, reviews and evaluates problems for prompt solutions. * Determines, adapts, and ...

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Utilization Review information

What is a utilization review?

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 does a utilization review do?

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 are the key skills and qualifications needed to thrive in utilization review?

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 or related degree such as nursing, health administration, or social work is required. Certification in case management or utilization review, like the Certified Professional in Healthcare Quality (CPHQ), can enhance job prospects, and strong analytical and communication skills are essential for success in the role.

Is utilization review a stressful job?

Utilization review is a healthcare role that involves evaluating medical necessity and appropriateness of services, often under strict deadlines and documentation requirements. The job can be stressful due to high workload, the need for accuracy, and managing complex cases, but stress levels vary based on work environment and individual coping skills.

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 August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 13% Part Time, 3% Contract, and 1% Nights. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution.

Utilization Coordinator

San Juan Capestrano

San Juan, PR

Full-time

Re-posted 2 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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