ZipRecruiter

Log In

1

Virtual Utilization Review Specialist Jobs (NOW HIRING)

ADP, Inc.

Utilization Review Specialist

Knoxville, TN · On-site

The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This ...

Socket.dev

Utilization Review Specialist

Knoxville, TN · On-site

The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This ...

next page

Showing results 1-20

All JobsHealthcare JobsNursing JobsNurse Case Manager JobsVirtual Utilization Review Specialist Jobs

Virtual Utilization Review Specialist information

See salary details

$15

$31

$53

How much do virtual utilization review specialist jobs pay per hour?

As of Sep 14, 2026, the average hourly pay for virtual utilization review specialist in the United States is $31.94, according to ZipRecruiter salary data. Most workers in this role earn between $22.36 and $40.62 per hour, depending on experience, location, and employer.

What is a virtual utilization review specialist?

Virtual Utilization Review Specialists are healthcare professionals who assess the necessity, efficiency, and appropriateness of medical services provided to patients, typically working remotely. They review patient records and treatment plans to ensure they meet established guidelines and payer requirements. Their work helps optimize patient care, control healthcare costs, and ensure compliance with insurance policies. These specialists often collaborate with physicians, nurses, and insurance companies using digital tools and secure platforms.

How does a virtual utilization review specialist typically collaborate with healthcare providers and insurance companies while working remotely?

As a Virtual Utilization Review Specialist, you'll regularly interact with healthcare providers and insurance representatives through secure digital platforms, email, and phone calls. Your role involves reviewing patient records, clarifying treatment plans, and ensuring documentation meets payer requirements for medical necessity. Effective communication and strong organizational skills are essential, as you'll need to coordinate with multiple parties, handle confidential information, and resolve discrepancies promptly. Most specialists work independently within a broader clinical or case management team, participating in virtual meetings to discuss complex cases and stay updated on regulatory changes.

What are the key skills and qualifications needed to thrive as a virtual utilization review specialist, and why are they important?

To excel as a Virtual Utilization Review Specialist, you need a background in nursing or healthcare, strong knowledge of clinical guidelines, and relevant licensure (such as RN or LPN). Familiarity with electronic medical record (EMR) systems, utilization management software, and UM certification (like CCM or URAC) is typically required. Outstanding analytical thinking, attention to detail, and effective communication skills are crucial for collaborating with healthcare providers and advocating for appropriate care. These competencies are vital to ensuring accurate case reviews, optimal patient outcomes, and adherence to regulatory and payer requirements in a remote setting.

What is the difference between Virtual Utilization Review Specialist vs Virtual Case Manager?

AspectVirtual Utilization Review SpecialistVirtual Case Manager
CredentialsTypically requires healthcare-related certifications (e.g., RN, CPC)Often requires social work, nursing, or healthcare certifications
Work EnvironmentRemote, focused on reviewing medical necessity and insurance claimsRemote, involved in coordinating patient care and discharge planning
Employer & IndustryInsurance companies, healthcare providers, third-party administratorsHospitals, insurance companies, healthcare agencies

The Virtual Utilization Review Specialist primarily evaluates medical necessity for insurance claims, focusing on reviewing patient records remotely. In contrast, the Virtual Case Manager manages patient care plans and coordinates services virtually. Both roles require healthcare certifications and operate in similar remote environments, but their core responsibilities differ in focus and daily tasks.

What cities are hiring for Virtual Utilization Review Specialist jobs?

Cities with the most Virtual Utilization Review Specialist job openings:

What are the most commonly searched types of Utilization Review Specialist jobs?

The most popular types of Utilization Review Specialist jobs are:

What states have the most Virtual Utilization Review Specialist jobs?

States with the most job openings for Virtual Utilization Review Specialist jobs include:

What are popular job titles related to Virtual Utilization Review Specialist jobs?

For Virtual Utilization Review Specialist jobs, the most frequently searched job titles are:

Infographic showing various Virtual Utilization Review Specialist job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $66,436 per year, or $31.9 per hour.

Sr. Virtual Utilization Review Specialist

Remote

Ensemble Health Partners, Inc.
Health Care and Social Assistance • 5 - 10K employees
Learn more about Ensemble Health Partners, Inc.external

$32.65 - $43.90/hr

Full-time

Medical, Retirement

Re-posted 21 days ago

Ensemble Health Partners rating

6.6

Company rating: 6.6 out of 10

Based on 246 frontline employees who took The Breakroom Quiz

Job description

Thank you for considering a career at Ensemble!
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.
Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!
O.N.E Purpose:
  • Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
  • Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
  • Striving for Excellence: Execute at a high level by demonstrating our "Best in KLAS" Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity:
CAREER OPPORTUNITY OFFERING:
  • Bonus Incentives
  • Paid Certifications
  • Tuition Reimbursement
  • Comprehensive Benefits
  • Career Advancement

This position pays between $32.65/hr - $43.90/hr based on experience
**Must have current RN compact license**
Please note that the VUR department operates 7 days per week from 8:00 a.m. to 10:00 p.m., and candidates must be willing and able to work within these scheduled hours, including weekends as needed.
We are seeking Virtual Utilization Review Specialists to join our team.
Essential job function include:
Resource Utilization
  • Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services
  • Initiates appropriate referral to physician advisor in a timely manner
  • Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team
  • Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers

Medical Necessity Determination
  • Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews, possibly from an offsite location
  • Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission
  • Communicates all medical necessity review outcomes to in-house care management staff and relevant parties as needed
  • Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care
  • Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers

Denial Management
  • Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process.
  • Maintains appropriate information on file to minimize denial rate
  • Assist in recording denial updates; overturned days and monitor and report denial trends that are noted
  • Monitor for readmissions

Quality/Revenue Integrity
  • Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators
  • Accurately records data for statistical entry and submits information within required time frame
  • Responsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflow
  • Accurately records data for statistical entry and submits information within required time frame
  • Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management
  • Second-level physician reviews will be sent as required and responses/actions reflected in documentation

Facilitation of Patient Care
  • Prioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria
  • Collaborates with the in-house care manager Maintains rapport and communication with the in-house care manager Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment
  • Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures

Communication
  • Directs physician and patient communication regarding non-coverage of benefits
  • Maintains positive, open communication with the physicians, nurses, multidisciplinary team members and administration
  • Educates hospital and medical staff regarding utilization review program.
  • Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis
  • Voicemail, Skype, and email will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours.
  • Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements
  • Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made

Team Affirmation
  • Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in and offers to help
  • Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities
  • Provides back-up support to other departmental staff as needed

Other Job Functions
  • Complies with FCC and department policies and procedure, including confidentiality and patient's rights.
  • Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities (i.e., medical necessity criteria, MS-DRGs, POA).
  • Actively participates in departmental meetings and activities.
  • Participates in FCC and community committees as assigned.
  • Actively participates in conferences, committees, and task forces as directed by the FCC division.
  • Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

Experience:
  • Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field
  • Current unrestricted RN license required; RN compact license preferred
  • Three years nursing experience in an acute care environment preferred
  • Utilization review/discharge planning experience preferred
  • Recent experience or working knowledge of medical necessity review criteria preferred
  • Current working knowledge of quality improvement processes

Other Knowledge, Skills, and Abilities Required:
  • This is a remote role which requires access to high speed internet
  • Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues
  • Commitment to exceptional customer service at all times
  • Communicate ideas and thoughts effectively verbally and in writing
  • Strong clinical assessment, organization and problem-solving skills
  • Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes
  • Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment
  • Resourceful and able to work independently
  • Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences
  • This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require

#LI-LS1
#LI-Remote
Join an award-winning company
Five-time winner of "Best in KLAS" 2020-2022, 2024-2025
Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024
22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024
Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024
Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023
Energage Top Workplaces USA 2022-2024
Fortune Media Best Workplaces in Healthcare 2024
Monster Top Workplace for Remote Work 2024
Great Place to Work certified 2023-2024
  • Innovation
  • Work-Life Flexibility
  • Leadership
  • Purpose + Values

Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:
  • Associate Benefits - We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
  • Our Culture - Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
  • Growth - We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
  • Recognition - We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.
Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com.
This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role's range.
Employment Disclaimers - Ensemble

What Ensemble Health Partners employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply