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Utilization Review Jobs in Virginia (NOW HIRING)

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which ...

Summit BHC

Utilization Assistant

Williamsburg, VA · On-site

Assists in utilization reviews and insurance appeals. Responds to inquiries from patients, their families, and professional referral sources. Roles and Responsibilities: • Assists the admissions ...

UHS

UTILIZATION COORDINATOR

Danville, VA

... review and respond to concerns expressed by customers. Together with the appropriate Department ... · Assist in preparing Utilization Review Reports as necessary. · Coordinates and makes ...

UHS

Director of Utilization Management

Danville, VA · On-site

Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, ... or LCP in Virginia required. EEO Statement All UHS subsidiaries are committed to providing an ...

State of Virginia

RNCA

Petersburg, VA · On-site

$84K - $116K/yr

Applications/resumes will begin to be reviewed within five (5) days of the posting date. Background Investigation: All applicants are subject to an extensive background investigation and a pre ...

GQR

RN - Case Manager

Falls Church, VA

$2K - $2K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Falls Church, Virginia Start Date: April 6, 2026 Profession: Registered Nurse (RN) Facility: Short Term Acute Care ...

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Utilization Review information

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How much do utilization review jobs pay per hour?

As of Jun 13, 2026, the average hourly pay for utilization review in Virginia is $41.92, according to ZipRecruiter salary data. Most workers in this role earn between $33.12 and $48.12 per hour, depending on experience, location, and employer.

What jobs pay $10,000 a month without a degree?

Utilization Review roles typically do not pay $10,000 a month without relevant experience or certifications; most positions in this field pay lower salaries. High-paying jobs that can reach this level without a degree often include specialized sales, real estate, or entrepreneurship, but they usually require significant skills, networking, or business acumen. Achieving such income without a degree generally involves gaining expertise, certifications, or building a successful independent business.

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.

What is the least stressful healthcare job?

Utilization review is often considered a less stressful healthcare job because it typically involves reviewing medical cases and insurance claims in a predictable, office-based environment. It usually requires strong analytical skills and certification but involves less direct patient interaction and emergency situations compared to clinical roles.

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 obtains certification in utilization review or case management. Gaining experience in healthcare settings and understanding insurance policies and medical coding can also improve job prospects. Certification programs like the Certified Professional in Healthcare Quality (CPHQ) or Certified Case Manager (CCM) are often preferred by employers.
What are the most commonly searched types of Utilization Review jobs in Virginia? The most popular types of Utilization Review jobs in Virginia are:
What are popular job titles related to Utilization Review jobs in Virginia? For Utilization Review jobs in Virginia, the most frequently searched job titles are:
What job categories do people searching Utilization Review jobs in Virginia look for? The top searched job categories for Utilization Review jobs in Virginia are:
What cities in Virginia are hiring for Utilization Review jobs? Cities in Virginia with the most Utilization Review job openings:
Utilization Review jobs near you
Infographic showing various Utilization Review job openings in Virginia as of June 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution, with an average salary of $87,192 per year, or $41.9 per hour.

Utilization Review/Continuous Quality Improvement Specialist

Frederick County, VA

Winchester, VA • On-site

$65K - $75K/yr

Full-time

Medical, Dental, Vision, Life

Posted 18 days ago

Job description

Salary: $65,280.00 - $75,000.00 Annually
Location : 107 N Kent. St., Winchester, VA
Job Type: Full-Time
Job Number: 00710
Department: CHILDREN'S SERVICES ACT
Opening Date: 05/26/2026
Description
We are seeking a detail-oriented and clinically driven UR/CQI Specialist to support quality assurance and continuous improvement efforts for Children's Services Act (CSA) programs. This role is responsible for reviewing high-risk and complex cases and ensuring that services are effective, family-centered, and compliant with CSA requirements and local policies. The ideal candidate will bring strong analytical skills, clinical expertise, and a commitment to improving outcomes for youth and families through collaboration, provider oversight, and data-informed recommendations.
What You'll Do:
ESSENTIAL DUTIES AND RESPONSIBILITIES:
  • Conduct utilization reviews for CSA-funded youth and family cases, including congregate care placements, high-utilization services, and other high-risk or clinically complex cases.
  • Review assessments, CANS, IFSPs, treatment plans, progress reports, and related documentation to ensure services are clinically appropriate, effective, and least restrictive and aligned with identified needs and CSA expectations.
  • Assess whether services are clinically appropriate, least restrictive, fiscally responsible, and responsive to the youth and family's documented needs, strengths, functioning, and treatment goals.
  • Conduct interviews and gather information from youth, families, caregivers, case managers, service providers, and partner agencies to support utilization review and continuous quality improvement efforts.
  • Prepare written UR/CQI findings, summaries, and recommendations, and provide professional guidance to FAPT, IFT, and other multidisciplinary teams regarding level of care, treatment progress, discharge planning, service alternatives, and service gaps.
  • Monitor provider compliance with contractual expectations, treatment planning requirements, monthly reporting standards, incident reporting, licensing concerns, and overall quality-of-care expectations through chart reviews, provider meetings, and site visits.
  • Track service utilization patterns, treatment outcomes, provider performance concerns, and systemic barriers to support continuous quality improvement initiatives, outcome monitoring, and programmatic enhancements.
  • Provide consultation and technical assistance related to CANS-informed service planning, evidence-based interventions, progress monitoring, discharge planning, audits, policy implementation, training activities, and confidentiality compliance.
  • Maintains confidential records and communications in accordance with CSA requirements, local policies, HIPAA/FERPA, where applicable, and other confidentiality requirements.
  • Performs other duties as assigned.

What We're Looking For:
EDUCATION: Master's Degree in Social Work, Counseling, Psychology, Marriage and Family Therapy, Human Services, or a closely related field required.
EXPERIENCE: Minimum one year of experience in behavioral health, child welfare, juvenile justice, special education, or children's services required. Experience with utilization review, treatment planning, residential care, Medicaid behavioral health services, CSA, CANS, or provider quality assurance preferred. Related internship experience may be considered.
CERTIFICATES, LICENSES AND/OR REGISTRATIONS: Clinical license or license-eligible status in Virginia preferred. Must be proficient in the CANS and become certified as a CANS SuperUser within 30 days of employment or within the timeframe approved by the CSA Coordinator. Must possess a valid driver's license.
OTHER KNOWLEDGE, SKILLS AND ABILITIES: Requires strong clinical assessment, documentation review, analytical, written, and verbal communication skills. Ability to interpret and apply complex policies, contracts, and treatment documentation while exercising sound clinical judgment in time-sensitive situations. Must collaborate effectively with families, providers, and partner agencies, manage conflict professionally, and work independently under strict deadlines. Proficiency with Microsoft 365 and standard office technology required. Knowledge of CSA, CANS, Medicaid behavioral health services, evidence-based practices, and licensing standards preferred.
Supplemental Information
PHYSICAL DEMANDS: Requires regular physical activity, including walking, standing, sitting, writing, typing, bending, and operating office equipment. Work involves preparing and analyzing data and observing community and service settings. Must be able to travel independently to provider sites, schools, courts, homes, and other community locations approximately 25-50% of the time.
ENVIRONMENTAL CONDITIONS: Primary workspace is a heated and air-conditioned office. Duties require travel to provider locations, schools, homes, meetings, and other community settings as assigned. In-person attendance at FAPT, provider meetings, site visits, and other meetings may be required based on operational needs.
To learn more about Frederick County, Virginia employee benefits, please visit the following webpage:
All positions are subject to a criminal background check for any convictions that relate to the job duties and responsibilities. Frederick County Virginia Government is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
The County's EEO Utilization Report is available at www.fcva.us/jobs
There are a wide variety of benefits available to Frederick County employees. These benefits include: health, dental, vision, life insurance, optional life and disability plans, flexible spending account for health care, dependent care assistance program, an employee assistance program and a deferred compensation program.
Please click to view our Frederick County Employee Benefits information page with full details on all insurance plans offered.

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