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Utilization Reviewer Jobs in Reston, VA (NOW HIRING)

Inova

Director, Case Management

Leesburg, VA · On-site

Leads all utilization review, social work and discharge planning activities within assigned operating unit. * Oversees the day to day operation of all Case Management related activities to include ...

Trinityhealth

Physican-OB/GYN

Germantown, MD

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Trinity Health

Physican-OB/GYN

Silver Spring, MD

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Trinityhealth

Physican-OB/GYN

Silver Spring, MD

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Trinity Health

Physican-OB/GYN

Silver Spring, MD · On-site

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Trinity Health

Physican-OB/GYN

Germantown, MD · On-site

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Trinity Health

Physican-OB/GYN

Silver Spring, MD · On-site

$61.25 - $140/hr

Participate in quality, risk, and utilization review processes. * Supervise and teach residents and other learners within the hospital. * Support and promote Holy Cross Hospital's perinatal safety ...

Evolent

Oncology - Radiation Physician

Arlington, VA

Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU s policies/procedures, as well as ...

Evolent

Oncology - Radiation Physician

Arlington, VA · On-site

Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU s policies/procedures, as well as ...

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Showing results 1-20

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 Jul 23, 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 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 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 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.

How to become a utilization reviewer?

To become a utilization reviewer, candidates typically need a healthcare-related degree such as nursing, health administration, or a related field. Relevant experience in healthcare or insurance, strong analytical skills, and knowledge of medical coding and documentation are important; some employers may also require certification such as the Certified Professional Medical Auditor (CPMA).

Is utilization review a stressful job?

Utilization reviewers often work in a fast-paced environment where accuracy and attention to detail are essential, which can contribute to job stress. The role may involve managing high caseloads and strict deadlines, but stress levels vary depending on the work setting and individual coping strategies.

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, and why are they important?

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.

Is utilization review work from home?

Utilization reviewer jobs can often be performed remotely, especially in organizations that utilize electronic health records and telecommunication tools. Many employers offer work-from-home options for this role, which typically requires strong analytical skills, knowledge of healthcare policies, and certification in case management or utilization review. However, some positions may require on-site presence depending on company policies and regulatory requirements.

What jobs pay 4000 a week without a degree?

Utilization reviewers typically do not earn $4,000 a week without a degree; this role usually requires healthcare or insurance industry experience and certifications. High-paying jobs that can reach this level without a degree often include sales, real estate, or skilled trades like plumbing or electrical work, which rely on experience and skills rather than formal education.
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 July 2026, with employment types broken down into 84% Full Time, 9% Part Time, 3% Contract, and 4% Nights. Highlights an 59% Physical, 2% Hybrid, and 39% Remote job distribution, with an average salary of $39,525 per year, or $19 per hour.

Nursing Subject Matter Expert

R3 Management Services

Washington, DC • Remote

$17.50 - $20.50/hr

Part-time

Posted 2 days ago

Job description

Nursing Subject Matter Expert

Position Overview

The Nursing Subject Matter Expert provides professional nursing expertise related to healthcare operations, clinical quality, medical-record review, program assessment, corrective-action monitoring, and technical assistance.

This position evaluates the effectiveness of nursing and healthcare-delivery operations across Job Corps centers and recommends improvements to the quality, safety, compliance, and consistency of student health services. This position may be part-time.

Key Responsibilities

  • Provide professional nursing consultation regarding adolescent and young-adult healthcare.
  • Monitor and evaluate the effectiveness of healthcare-delivery operations.
  • Review applicant and student health records and center recommendations.
  • Support clinical reviews involving enrollment decisions, healthcare needs assessments, medical separations, appeals, and complex health concerns.
  • Participate in comprehensive and targeted assessments of center health and wellness programs.
  • Review nursing documentation, medication-management practices, chronic-illness management, care coordination, immunization processes, preventive-health activities, and nursing operations.
  • Determine whether nursing and healthcare services meet professional, clinical, and program requirements.
  • Identify deficiencies and recommend corrective actions.
  • Review corrective action plans and monitor implementation.
  • Identify repeat findings and recommend additional corrective measures.
  • Provide virtual or onsite technical assistance to national, regional, and center health personnel.
  • Advise personnel on difficult nursing cases, chronic-disease management, preventive care, health education, and healthcare-delivery improvements.
  • Assist with developing or revising nursing policies, procedures, technical guides, training materials, and healthcare publications.
  • Conduct conference calls, webinars, consultations, and training for health and wellness managers, nurses, and other personnel.
  • Prepare assessment reports, record-review findings, recommendations, meeting notes, and monthly activity reports.
  • Coordinate with medical, mental health, substance-use prevention, and program-management personnel.
  • Protect confidential student, medical, and personal information.

Qualifications/Experience

  • Bachelor of Science in Nursing required.
  • Current Registered Nurse license.
  • Minimum of 5 years of experience monitoring the effectiveness of healthcare-delivery operations.
  • Experience with program evaluation and assessment.
  • Experience with quality and compliance assessment techniques.
  • Experience conducting medical-record reviews.
  • Knowledge of healthcare-delivery systems.
  • Knowledge of adolescent health and wellness issues.
  • Experience with crisis intervention.
  • Experience in clinical quality, case management, utilization review, public health, school health, community health, nursing administration, or residential youth healthcare is preferred.
  • Experience supporting multi-site or geographically dispersed healthcare operations is preferred.

Required Skills

  • Nursing operations and clinical oversight.
  • Healthcare quality and compliance.
  • Medical-record review.
  • Chronic-illness and case-management principles.
  • Program evaluation and assessment.
  • Corrective-action development and monitoring.
  • Adolescent and young-adult health.
  • Crisis intervention.
  • Health education and staff training.
  • Technical writing and report preparation.
  • Strong time-management and organizational skills.
  • Strong written and verbal communication.
  • Multidisciplinary collaboration.
  • Strong computer skills.

Certification

Must maintain a current Registered Nurse license. Bachelor of Science in Nursing is required. Certifications in case management, healthcare quality, public health nursing, nursing administration, or utilization review are preferred.

Clearance/Security

Must possess or be eligible to obtain and maintain a Public Trust clearance. Must comply with privacy, confidentiality, medical-record, and information-security requirements.

Salary

TBD