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Case Manager Utilization Review Nurse Jobs (NOW HIRING)

Ova Technologies

Utilization Review Nurse

Alpharetta, GA · On-site

Utilization Review Nurse Location: [City, State / Remote] Employment Type: Full-Time Experience: 2 ... Collaborate with physicians, case managers, discharge planners, and interdisciplinary healthcare ...

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HOPCO

RN Case Manager - Utilization Review

Phoenix, AZ · On-site

Case Manager/Utilization Review Nurse At The CORE Institute, we are dedicated to taking care of you so you can take care of business! Our robust benefits package includes the following: * Competitive ...

Care Career

Travel Utilization Review RN

Tuba City, AZ · On-site

Care Career is seeking a travel nurse RN Case Manager, Utilization Review for a travel nursing job in Tuba City, Arizona. & Requirements * Specialty: Utilization Review * Discipline: RN * Start Date ...

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Case Manager Utilization Review Nurse information

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How much do case manager utilization review nurse jobs pay per hour?

As of Aug 7, 2026, the average hourly pay for case manager utilization review nurse in the United States is $47.53, according to ZipRecruiter salary data. Most workers in this role earn between $35.34 and $57.45 per hour, depending on experience, location, and employer.

What is the difference between Case Manager Utilization Review Nurse vs Case Manager?

AspectCase Manager Utilization Review NurseCase Manager
CredentialsRN license, certification in utilization review (e.g., URAC)RN license, case management certification (e.g., CCM)
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, community health, insurance providers
Primary FocusReviewing medical necessity and appropriateness of careCoordinating patient care and discharge planning

While both roles involve patient care coordination, the Case Manager Utilization Review Nurse primarily focuses on reviewing medical necessity and insurance approvals, whereas the Case Manager handles broader patient care coordination and discharge planning. Both roles require nursing credentials and are vital in healthcare settings, but their specific responsibilities differ.

How does a case manager utilization review nurse typically collaborate with physicians and other healthcare providers?

Case Manager Utilization Review Nurses regularly work with physicians, social workers, and other healthcare professionals to ensure patients receive appropriate care while managing resource utilization. They often participate in interdisciplinary team meetings to discuss care plans, review patient progress, and address any barriers to discharge. Building strong communication channels and maintaining up-to-date clinical knowledge are essential, as nurses must advocate for patients while also supporting evidence-based practices and regulatory compliance. This collaborative environment helps streamline patient care and optimize outcomes.

What is a case manager utilization review nurse?

A Case Manager Utilization Review Nurse is a registered nurse who evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, coordinate with healthcare providers, and ensure that treatments meet established guidelines and insurance requirements. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulations. These nurses also help facilitate communication between patients, providers, and payers to support effective care management.

What are the key skills and qualifications needed to thrive as a case manager utilization review nurse, and why are they important?

To excel as a Case Manager Utilization Review Nurse, you need a solid background in nursing, strong clinical assessment skills, and a valid RN license, often with case management certification. Familiarity with utilization review software, electronic health record (EHR) systems, and knowledge of insurance and regulatory guidelines is essential. Exceptional communication, critical thinking, and negotiation abilities set top performers apart in this role. These qualifications ensure effective patient advocacy, cost-effective care, and compliance with healthcare standards.

What does a case manager utilization review nurse do?

A case manager utilization review nurse evaluates medical cases to determine the necessity, appropriateness, and efficiency of healthcare services. They review patient records, collaborate with healthcare providers, and ensure treatment plans comply with insurance and regulatory guidelines, often using electronic health record systems. This role requires clinical nursing experience and knowledge of healthcare policies.
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What cities are hiring for Case Manager Utilization Review Nurse jobs? Cities with the most Case Manager Utilization Review Nurse job openings:
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Case Manager Utilization Review Nurse jobs near you
Infographic showing various Case Manager Utilization Review Nurse job openings in the United States as of August 2026, with employment types broken down into 88% Full Time, 11% Part Time, and 1% Contract. Highlights an 85% Physical, 2% Hybrid, and 13% Remote job distribution, with an average salary of $98,869 per year, or $47.5 per hour.

Case Manager / Utilization Review

Cibola General Hospital

Grants, NM • On-site

Full-time

Re-posted 13 days ago

Job description

Job Type
Full-time
Description
The Case Manager / Utilization Review Nurse (RN) is responsible for coordinating patient care progression, discharge planning, and utilization review activities. This integrated role ensures appropriate levels of care, regulatory compliance, efficient resource utilization, and optimal patient outcomes.
The position combines clinical Case Management functions with Utilization Review responsibilities, including medical necessity reviews, inpatient and concurrent authorizations, concurrent reviews, denial prevention, and interdisciplinary collaboration. The Case Manager / Utilization Review Nurse serves as a liaison between patients, families, providers, payers, and post-acute resources to facilitate safe, timely, and cost-effective transitions of care while supporting hospital reimbursement integrity and compliance with Medicare, Medicaid, commercial payer, and regulatory requirements.
Case Management Responsibilities
  • Perform comprehensive patient assessments to identify clinical, psychosocial, financial, and discharge planning needs.
  • Coordinate patient care progression and discharge planning throughout the hospitalization.
  • Identify barriers to discharge and collaborate with interdisciplinary teams to facilitate timely patient progression.
  • Coordinate referrals and post-acute services, including:
  • Home Health
  • Long-Term Care (LTC)
  • Skilled Nursing Facilities (SNF)
  • Durable Medical Equipment (DME)
  • Community resources and support services
  • Collaborate with patients, families, providers, nursing staff, therapy services, and ancillary departments regarding discharge planning and transition needs.
  • Provide patient and family education on discharge plans, available resources, and support services.
  • Coordinate advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
  • Participate in interdisciplinary rounds and team meetings to discuss patient progression and discharge readiness.
  • Ensure timely and accurate Case Management documentation in the electronic health record (EHR).

Utilization Review Responsibilities
  • Perform concurrent and retrospective utilization reviews for patient admissions and continued stays using established medical necessity criteria (e.g., MCG, InterQual) and payer-specific guidelines.
  • Determine and reassess appropriate patient status, including inpatient versus observation levels of care.
  • Obtain inpatient and concurrent authorizations for services in accordance with payer requirements and established timelines.
  • Obtain prior authorizations and manage authorization workflows for inpatient and outpatient services as assigned.
  • Submit initial and concurrent clinical documentation to payers within required timelines.
  • Communicate effectively with physicians and other providers regarding medical necessity, documentation requirements, level-of-care determinations, and alternative levels of care.
  • Monitor for avoidable days, delays in care progression, and opportunities to improve patient throughput.
  • Identify and proactively address potential denials and reimbursement risks.
  • Assist with preparation and submission of denial appeals, including supporting clinical rationale and documentation.
  • Document all utilization review activities, approvals, denials, authorizations, and payer communications accurately in the EHR.
  • Monitor readmissions, avoidable days, and utilization trends to support quality improvement initiatives.
  • Participate actively in Utilization Review (UR) Committee activities and related compliance initiatives.
  • Provide education to providers and staff regarding medical necessity documentation and payer requirements.

Requirements
Required Qualifications
  • Active, unrestricted Registered Nurse (RN) license in New Mexico or a Compact State.
  • Minimum of 2-3 years of recent acute care clinical experience.
  • Strong knowledge of Medicare and Medicaid regulations, commercial payer guidelines, and medical necessity criteria (MCG and/or InterQual).
  • Excellent critical thinking, analytical, and problem-solving skills.
  • Strong verbal and written communication skills.
  • Ability to work independently while managing multiple priorities in a fast-paced environment.
  • Proficiency with electronic health record systems (Cerner preferred) and related software applications.

Preferred Qualifications
  • Previous Case Management and/or Utilization Review experience in an acute care setting.
  • Experience with inpatient and concurrent authorization management, concurrent reviews, denial prevention, appeals, discharge planning, and care coordination.
  • Critical Access Hospital (CAH) experience preferred.
  • Knowledge of CMS Conditions of Participation, utilization management best practices, and payer authorization processes.

Work Environment
  • Acute care hospital setting.
  • Combination of patient-facing and office-based responsibilities.
  • Frequent interaction with interdisciplinary clinical teams, payers, patients, and families.
  • Fast-paced, collaborative environment requiring effective prioritization and workflow management.

Core Competencies
  • Clinical judgment and medical necessity review
  • Care coordination and discharge planning
  • Regulatory compliance and payer guideline knowledge
  • Communication and interdisciplinary collaboration
  • Time management and organizational skills
  • Problem-solving and denial prevention strategies

Physical Requirements
  • Ability to sit, stand, walk, and use standard office and computer equipment for extended periods.
  • Ability to review electronic medical records and documentation efficiently.
  • Occasional movement throughout patient care areas and hospital departments.

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