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Utilization Reviewer Jobs in Edmond, OK (NOW HIRING)

UHS

UR Coordinator

Oklahoma City, OK · On-site

Responsibilities The Utilization Review Coordinator evaluates patient medical records to determine severity of patient's illness and the appropriateness of level of care. Serves as liaison for ...

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Utilization Reviewer information

See Edmond, OK salary details

$28K

$34.3K

$39.8K

How much do utilization reviewer jobs pay per year?

As of Sep 5, 2026, the average yearly pay for utilization reviewer in Edmond, OK is $34,326.00, according to ZipRecruiter salary data. Most workers in this role earn between $30,700.00 and $37,900.00 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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The top searched job categories for Utilization Reviewer jobs in Edmond, OK are:

What cities near Edmond, OK are hiring for Utilization Reviewer jobs?

Cities near Edmond, OK with the most Utilization Reviewer job openings:

Utilization Reviewer jobs near you
Infographic showing various Utilization Reviewer job openings in Edmond, OK as of August 2026, with employment types broken down into 68% Full Time, and 32% Part Time. Highlights an 73% In-person, and 27% Remote job distribution, with an average salary of $33,873 per year, or $16.3 per hour.

RN Claims Review and Utilization Management

MedTrust LLC

Oklahoma City, OK • On-site

Full-time

Re-posted 14 days ago

Job description

The utilization review and management (UM) component program ensures that external healthcare services provided across MedTrust/MedHealth contracted facilities are medically necessary, clinically appropriate, evidence-based, and delivered at the appropriate level of care, while supporting regulatory compliance and organizational risk management. The Joint Commission Compliance component ensures MedTrust stays complaint with applicable Joint Commission (JC) standards. MedTrust proudly holds the Gold Seal of Approval from the Joint Commission, recognizing our commitment to quality, safety, and excellence in healthcare staffing. This position ensures that MedTrust/MedHealth is fully compliant in both areas. These two components are referred to below as UMJC.

Essential Functions:

  1. Oversee UMJC: Handle the utilization review and management process to ensure the appropriate and cost-effective use of healthcare resources. This includes evaluating treatment plans and ensuring compliance with regulatory requirements. Ensure compliance with JC standards, including file reviews, monthly safety plans and uploading data to the JC web page. This will include assisting with the logging and documentation of claims along the process chain.
  2. Collaboration: Work closely with medical staff, case managers, and other healthcare professionals to assess the medical necessity of treatments and coordinate care effectively
  3. Data Analysis: Analyze utilization data and trends to identify opportunities for improving efficiency and reducing unnecessary costs. This involves monitoring the performance of healthcare providers and implementing corrective action plans as needed
  4. Documentation and Compliance: Maintain accurate documentation of all UMJC activities, ensuring compliance with organizational policies and regulatory requirements. This includes collaborating with hospitals and providers and resolving any utilization-related issues
  5. Timeliness: Ensure that claims received are accurately logged and reviewed within seven (7) days of receipt and forwarded promptly to the next step in the process to ensure all claims are ultimately paid timely. It will be this person’s responsibility to notify appropriate management if claims are not being timely received for processing.
  6. Quality Improvement Initiatives: Participate in the development and implementation of quality improvement initiatives to enhance patient care outcomes and operational efficiency
  7. Joint Commission (JC) Functions: Maintain accurate and up-to-date documentation and compliance records. Serves as the medical lead during joint commission surveys and audits, including preparation of staff and materials. Keeps up-to-date on JC requirements and rules.

Qualifications

  • Registered nurse with active, unincumbered nursing licensed in Oklahoma and willing and able to get licensed in other states where MedTrust/MedHealth do business. Master’s degree is preferred.
  • Relevant experience in utilization review, utilization management/case management is essential.
  • Prior experience with Joint Commission compliance is a plus.
  • 3-5 years of healthcare experience required.

Knowledge and Skills

  • Analytical Skills: Strong analytical and problem-solving skills to assess data and make informed decisions regarding patient care and resource utilization
  • Communication Skills: Excellent communication and interpersonal skills to collaborate effectively with healthcare teams and patients
  • Knowledge of Regulations: Familiarity with healthcare regulations, insurance policies, and quality improvement processes is crucial for success in these roles
  • Knowledge of Joint Commission: Familiarity with joint commission requirements and duties.
  • Working knowledge of and familiarity with Microsoft Word and Excel.
  • Strong organization skills, with ability to work in fast paced environment.

Working Conditions and Environment

  • Must pay attention to detail-visual & mental
  • Must be able to multi-task
  • Ability to work independently without direct supervision
  • Ability to perform under stress
  • Ability to work with individuals at all levels of the organization to foster teamwork
  • While varied hours are required occasionally, normal office hours are 8 am – 5 pm with one hour for lunch
  • This is an in-office, no remote work capability position

Travel

  • Some travel may be required, but should be minimal and notice will be provided if necessary


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