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Utilization Reviewer Jobs Near Me

Humana

Utilization Management RN

Columbus, OH · On-site

Become a part of our caring community The Utilization Management Nurse, National Medicaid Clinical ... The RN Review Nurse works closely with healthcare providers, interdisciplinary teams, and non ...

syfs

UR Manager

Columbus, OH · On-site

For billing and hospitalization utilization review purposes, the reviewer will identify and certify the acute hospitallength of stay authorized for each case. Initiate and maintain medical records ...

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As of Aug 12, 2026, the average yearly pay for utilization reviewer in the United States is $37,992.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,000.00 and $42,000.00 per year, depending on experience, location, and employer.
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A map of the United States highlighting the number of Utilization Reviewer job openings by state according to ZipRecruiter. The image is accompanied by a detailed chart listing the number of Utilization Reviewer job openings in each state, with California having the most at 2 and Alaska the least at 0.

Utilization Review Specialist - Autism

Nationwide Children's Hospital

Columbus, OH • On-site

Full-time

Posted 21 days ago

Nationwide Children's Hospital rating

6.9

Company rating: 6.9 out of 10

Based on 131 frontline employees who took The Breakroom Quiz

553rd of 1,058 rated hospitals

Job description

Overview:
Schedule: Monday-Friday (8:00am-4:30pm)
Position is work from home after a 90 day in-office training period.
Job Description Summary:
Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.
Job Description:
Essential Functions:
  • Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
  • Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
  • Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
  • Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
  • Provides education and support regarding utilization review and management activities and processes.
  • Analyzes clinical data to identify trends and patterns that may impact patient care. Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
  • Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.

Education Requirement:
Bachelor's Degree in Social Work, Psychology, or related field, required.
Licensure Requirement:
(not specified)
Certifications:
(not specified)
Skills:
  • Excellent written and verbal communication and interpersonal skills.
  • Excellent customer service and organizational skills.
  • Working knowledge of CMS and other review agency standards.
  • Proficient with software applications including CM, payer web applications, MITS, and others.

Experience:
  • Three years of behavioral health experience, required.
  • One year of experience in pediatric care or services, required.
  • Utilization review or utilization management experience, preferred.

Physical Requirements:
OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting
Additional Physical Requirements performed but not listed above:
(not specified)
"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"

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About Nationwide Children's Hospital

Sourced by ZipRecruiter

Nationwide Children's Hospital, established in 1894, is a leading pediatric healthcare system based in Columbus, Ohio, United States. They serve as a primary pediatric network, providing wellness, preventive, diagnostic, treatment, and rehabilitative care for infants, children, adolescents, and adults with congenital disease. Being the third-largest pediatric hospital in the nation, Nationwide Children's Hospital prides itself on its relentless commitment to children and their families, driven by their core values of respect, integrity, determination, empathy, and solidarity. The institution's comprehensive mission is to enhance the health of children by providing high-quality, family-centered care, conducting groundbreaking research, advocating for pediatric health, and training top healthcare professionals.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Columbus, OH, US

Year founded

1892

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