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Utilization Review Jobs in Philadelphia, PA (NOW HIRING)

Penn Medicine

Utilization Review Nurse

West Chester, PA · On-site

The Utilization Review Nurse will provide utilization review for authorization, concurrent review and discharge review services using InterQual criteria guidelines to validate medical necessity and ...

IntePros

Utilization Review Nurse

Philadelphia, PA · On-site

This role is responsible for performing utilization management reviews to determine the medical necessity of requested healthcare services, ensuring members receive appropriate, evidence-based care ...

ABHS

Utilization Review Specialist

Evesham, NJ · On-site

General Description The Utilization Review Specialist processes all insurance authorizations for partial hospitalization programs, intensive outpatient programs and outpatient programs across ...

New

Genex Services

Utilization Reviewer 2

Wayne, PA · On-site

$52K - $76K/yr

The ideal candidate performs utilization review on workers' compensation related prospective, concurrent, and retrospective treatment referrals. The ideal candidate will play a crucial role in ...

Enlyte

Utilization Reviewer 2

Wayne, PA · On-site

$52K - $76K/yr

The ideal candidate performs utilization review on workers' compensation related prospective, concurrent, and retrospective treatment referrals. The ideal candidate will play a crucial role in ...

Enlyte

Utilization Reviewer 2

Wayne, PA

$52K - $76K/yr

The ideal candidate performs utilization review on workers' compensation related prospective, concurrent, and retrospective treatment referrals. The ideal candidate will play a crucial role in ...

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All JobsUtilization Review JobsUtilization Review Jobs in Philadelphia, PA

Utilization Review information

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How much do utilization review jobs pay per hour?

As of Aug 29, 2026, the average hourly pay for utilization review in Philadelphia, PA is $42.67, according to ZipRecruiter salary data. Most workers in this role earn between $33.70 and $48.99 per hour, depending on experience, location, and employer.

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 Philadelphia, PA?

The most popular types of Utilization Review jobs in Philadelphia, PA are:

What are popular job titles related to Utilization Review jobs in Philadelphia, PA?

For Utilization Review jobs in Philadelphia, PA, the most frequently searched job titles are:

What job categories do people searching Utilization Review jobs in Philadelphia, PA look for?

The top searched job categories for Utilization Review jobs in Philadelphia, PA are:

What cities near Philadelphia, PA are hiring for Utilization Review jobs?

Cities near Philadelphia, PA with the most Utilization Review job openings:

Utilization Review jobs near you
Infographic showing various Utilization Review job openings in Philadelphia, PA as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 3% Contract, and 1% Nights. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $84,053 per year, or $40.4 per hour.

Utilization Review Nurse

West Chester, PA • On-site

Pennsylvania Medicine

7.6

Company rating: 7.6 out of 10

Based on 352 frontline employees who took The Breakroom Quiz

189th of 895 rated healthcare providers

People enjoy working here

Good employer

Recommended by students

Learn more about Pennsylvania Medicineexternal

Other

Posted 18 days ago

Job description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
Summary:

  • The Utilization Review Nurse will provide utilization review for authorization, concurrent review and discharge review services using InterQual criteria guidelines to validate medical necessity and appropriateness of the treatment plan. Uses critical thinking/leadership skills to ensure patients are at appropriate level of care, safely transitioned across the healthcare continuum, and third-party payor standards are met. Reports same to the Utilization Review Committee responsible for ensuring appropriate utilization review practices to decrease LOS/readmissions, prevent financial loss and lower financial risk. The Utilization Nurse will seek out and resolve discrepancies/delays in the care delivery process. Assures appropriate services are generated in a timely and cost-effective manner.
Responsibilities:
  • Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
    Assesses patient progress through the expected in-house course, mobilizing resources of the patient care team to ensure patient outcomes are achieved as planned.
    Is the liaison between third party payors and actively participates in denial management activities.
    Works with physicians in documenting medical care to accurately and completely reflect intensity of service and severity of illness.
    Evaluates the appropriateness of continued stay by performing concurrent review and reviewing planned interventions with the physician. Makes appropriate recommendations for continued stay and/or modification of the care plan and course of treatment.
    Consults and advises members of the interdisciplinary team and ancillary staff to facilitate patients toward targeted outcomes.
    Collaborates appropriately with physician advisor to avoid denials.
    Serves as preceptor to new hires.
    Identifies trends in inappropriate utilization of resources, including, but not limited to, delays in diagnostic testing, medical surgical procedures and physician management.
    Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competence, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
    Communicates relevant clinical information including admission review, concurrent review and discharge planning needs, to third party payors to secure optimal reimbursement.
    Applies InterQual criteria to monitor appropriateness of admissions and continued stays and documents findings in the electronic health record.
    Follows 100% of assigned inpatient admissions
    Determines medical appropriateness of the patient's admission (severity of service)
    Monitors the plan of care and proactively identifies barriers to the plan (intensity of service)
    Intervenes to avoid delays in plan of care.
    Coordinates the flow of clinical information with third party payors to ensure appropriate reimbursement, proactively identifies potential denials in order to avoid non-appealable denials.
Credentials:
  • Registered Nurse - PA (Required)
  • Certified Case Manager
Education or Equivalent Experience:
  • Associate of Arts or Science (Required)
  • Major/Area of Study: Nursing/ASN 3+ years nursing experience
  • Bachelor of Arts or Science
  • Major/Area of Study: Nursing/BSN 3+ years nursing experience 1+ years utilization review
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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