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Utilization Reviewer Jobs in Reston, VA (NOW HIRING)

URAC

Clinical Accreditation Reviewer

Washington, DC · On-site

$120K - $135K/yr

For care management accreditation programs (i.e., utilization management, case management, health ... independent review, quality management, accreditation, or a related managed care function.

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All JobsUtilization Reviewer JobsUtilization Reviewer Jobs in Reston, VA

Utilization Reviewer information

See Reston, VA salary details

$32.3K

$39.5K

$45.8K

How much do utilization reviewer jobs pay per year?

As of Aug 21, 2026, the average yearly pay for utilization reviewer in Reston, VA is $39,525.00, according to ZipRecruiter salary data. Most workers in this role earn between $35,400.00 and $43,700.00 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.
More about Utilization Reviewer jobs

What are popular job titles related to Utilization Reviewer jobs in Reston, VA?

For Utilization Reviewer jobs in Reston, VA, the most frequently searched job titles are:

What job categories do people searching Utilization Reviewer jobs in Reston, VA look for?

The top searched job categories for Utilization Reviewer jobs in Reston, VA are:

What cities near Reston, VA are hiring for Utilization Reviewer jobs?

Cities near Reston, VA with the most Utilization Reviewer job openings:

Utilization Reviewer jobs near you
Infographic showing various Utilization Reviewer job openings in Reston, VA as of August 2026, with employment types broken down into 2% As Needed, 85% Full Time, 10% Part Time, and 3% Contract. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $39,525 per year, or $19 per hour.

Utilization Management Nurse

Luminis Health

Lanham, MD

$34 - $55/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 8 days ago

Luminis Health rating

7.9

Company rating: 7.9 out of 10

Based on 54 frontline employees who took The Breakroom Quiz

107th of 891 rated healthcare providers

Job description

Position Objective:  Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.  

Essential Job Duties:

1. Chart Review:

Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC

2. Denial Management:

Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial;  assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.

3. Care Coordination:

Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.

4.  Process improvement initiatives

Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Educational/Experience Requirements:

  • Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience.  BSN must be achieved within 5 years of start date in the role.  
  • Three years of clinical nursing in an acute care hospital setting.

RequiredLicense/Certifications:

  • Current RN license from Maryland Board of Nursing.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range
$34—$55 USD

Luminis Health Benefits Overview:
•    Medical, Dental, and Vision Insurance
•    Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
•    Paid Time Off
•    Tuition Assistance Benefits
•    Employee Referral Bonus Program
•    Paid Holidays, Disability, and Life/AD&D for full-time employees
•    Wellness Programs
•    Employee Assistance Programs and more
*Benefit offerings based on employment status

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