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Utilization Reviewer information

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$30.1K

$36.9K

$42.7K

How much do utilization reviewer jobs pay per year?

As of Sep 4, 2026, the average yearly pay for utilization reviewer in Maryland is $36,873.00, according to ZipRecruiter salary data. Most workers in this role earn between $33,000.00 and $40,800.00 per year, depending on experience, location, and employer.

What does a utilization reviewer do?

A Utilization Reviewer is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient records, treatment plans, and insurance policies to ensure that care meets established guidelines and standards. Their role helps control healthcare costs while maintaining quality patient care and ensuring compliance with regulatory requirements. Utilization Reviewers often communicate with healthcare providers, insurance companies, and patients to gather information and make informed decisions.

What does a utilization reviewer do?

There are different types of Utilization Reviewer jobs, including Nurse Utilization Reviewers, Insurance Utilization Reviewers, Speech Therapy, Physical Therapy, and Occupational Therapy Utilization Reviewers. Regardless of the area of focus, a Utilization Reviewer is responsible for setting best practices, reviewing healthcare program requirements, ensuring the quality of care, controlling costs, and developing and implementing initiatives for review processes. Utilization Reviewers ensure compliance of programs, regularly audit patient and client records, work with staff to implement best practices and correct problem areas, monitor industry trends, and remain up-to-date and train others on industry standards and requirements.

What are the key skills and qualifications needed to thrive as a utilization reviewer?

To thrive as a Utilization Reviewer, you need a clinical background (such as RN or LCSW), in-depth knowledge of medical terminology, and an understanding of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or URAC accreditation is typically required. Strong critical thinking, attention to detail, and effective communication skills help in evaluating patient care and collaborating with providers. These competencies are crucial for ensuring appropriate, cost-effective care while maintaining compliance with healthcare standards.

How does a utilization reviewer typically collaborate with healthcare providers to ensure appropriate patient care?

Utilization Reviewers work closely with physicians, nurses, and other healthcare professionals to assess the necessity and efficiency of medical services provided to patients. They review clinical documentation, verify that treatments meet established guidelines, and may discuss care plans directly with providers to clarify information or suggest alternatives. This collaboration ensures that patients receive appropriate care while controlling costs and complying with insurance or regulatory requirements. Effective communication and a thorough understanding of medical protocols are essential for success in this role.

What is the difference between Utilization Reviewer vs Medical Coder?

AspectUtilization ReviewerMedical Coder
Required CredentialsTypically requires healthcare-related certifications, such as RHIT, RHIA, or CPCUsually requires coding certifications like CPC, CCS, or CCS-P
Work EnvironmentHealthcare facilities, insurance companies, or utilization review organizationsHospitals, clinics, or medical billing companies
Employer & Industry UsageUsed in insurance, managed care, and healthcare administrationUsed in medical billing, coding, and health information management

While both roles work within healthcare settings, Utilization Reviewers focus on evaluating the necessity of medical services for insurance and care management, whereas Medical Coders translate medical records into standardized codes for billing and documentation. Understanding these differences helps professionals choose the right career path or job search focus.

How do I become a utilization review nurse?

To become a utilization review nurse, you typically need to hold a registered nurse (RN) license and have experience in clinical nursing. Additional certifications such as the Certified Professional Utilization Review (CPUR) or Certified Case Manager (CCM) can enhance job prospects, and strong knowledge of healthcare policies and documentation is essential.

Is utilization review a good job?

Utilization reviewers evaluate medical necessity and appropriateness of healthcare services, often working in healthcare or insurance settings. The role requires attention to detail, knowledge of healthcare policies, and sometimes certification, with typical schedules being standard business hours. It can offer stable employment and opportunities for advancement in healthcare administration.
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Utilization Reviewer jobs near you
Infographic showing various Utilization Reviewer job openings in Maryland as of August 2026, with employment types broken down into 2% As Needed, 87% Full Time, 10% Part Time, and 1% Contract. Highlights an 91% Physical, 2% Hybrid, and 7% Remote job distribution, with an average salary of $36,873 per year, or $17.7 per hour.

Utilization Reviewer

University of Maryland Medical System

Largo, MD • On-site

$406K/yr

Full-time

Re-posted 10 days ago

Key responsibilities

  • Performs utilization review for all patient populations using nationally recognized care guidelines/criteria.

  • Communicates with clinical care coordinators, physician advisors, medical team, and payors regarding reviews, pended/denied days, and interventions.

  • Ensures appropriate level of care and patient status, reviews tests and procedures for resource utilization, and supports the concurrent appeals process.

Job description

Job Requirements
Located in Largo in the heart of Prince George's County, our state-of-the-art regional medical center (University of Maryland Capital Region Medical Center) will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George's County residents.
Position Summary:
Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient's need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.
Primary Responsibilities:
Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
Supports concurrent appeals process through proactive identification of pended/denied days.
Implements the concurrent appeals process with appropriate referrals and documentation.
Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
Conducts HINN discussions/Observation Education.
Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
Ensures Regulatory Compliance related to Utilization Management conditions of participation.
Assures appropriate reimbursement and stewardship of organizational and patient resources.
Pursues and reports opportunities to improve reimbursement.
Collaborates with admitting specialists regarding authorization policies and procedures of third-party payers. Remains current on clinical practice and protocols impacting clinical reimbursement.
Work Experience
Education Bachelors in Nursing required.
Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
Two years' experience in acute care and four years clinical healthcare experience preferred.
Certified Professional Utilization Reviewer (CPUR) preferred.
Additional experience in home health, ambulatory care, and/or occupational health is preferred.
Knowledge, Skills and Abilities
1. Highly effective verbal and written skills are required.
2. Strong communication skills, self-confidence and experience in working with physicians are required.
3. Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.
4. The ability to work collaboratively with other disciplines is required.
5. Ability to work with Hospital/ Utilization Management and related software programs is required.
6. Knowledge of utilization management is preferred.
Benefits
Benefits
All your information will be kept confidential according to EEO guidelines.
Compensation:
• Pay Range: $40.61-$60.96
• Other Compensation (if applicable):
• Review the 2024-2025 UMMS Benefits Guide

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