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Case Manager Utilization Review Nurse Jobs in Washington

MedStar Health

RN Utilization Mgmt

Washington, DC · On-site

$89.07K - $162.80K/yr

... Manager will have 1-2 years of Utilization review- responsible for evaluating the necessity ... Makes referrals to Case Management as needed. * Sends thorough reviews to Medical Director as ...

GQR

RN - Case Manager

Falls Church, VA

$2.51K - $2.61K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Falls Church, Virginia Start Date: April 6, 2026 Profession: Registered Nurse (RN) Facility: Short Term Acute Care ...

MedStar Health

RN Utilization Management

Washington, DC · On-site

$89.07K - $162.80K/yr

Makes referrals to Case Management as needed. * Sends thorough reviews to Medical Director as ... utilization issues to appropriate MedStar personnel. Minimal Qualifications Education * Valid RN ...

Midland-Marvel

Director of Case Management

Dulles, VA

$120K - $130K/yr

Oversee utilization review and discharge planning processes * Ensure compliance with regulatory and ... Acute care hospital experience required; inpatient rehabilitation experience preferred * RN (BSN ...

Midland-Marvel

Director of Case Management

Dulles, VA

$120K - $130K/yr

Oversee utilization review and discharge planning processes * Ensure compliance with regulatory and ... Acute care hospital experience required; inpatient rehabilitation experience preferred * RN (BSN ...

CVS Health

Case Manager, Registered Nurse

Washington, DC · Remote

$54.10K - $155.54K/yr

The AHH RN Case manager position requires the nurse to support members across multiple states. A RN ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...

CVS Health

Case Manager, Registered Nurse

Washington, DC · Remote

$54.10K - $155.54K/yr

The AHH RN Case manager position requires the nurse to support members across multiple states. A RN ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...

CVS Health

Case Manager, Registered Nurse

Annapolis, MD · Remote

$54.10K - $155.54K/yr

The AHH RN Case manager position requires the nurse to support members across multiple states. A RN ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...

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Case Manager Utilization Review Nurse information

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.

How do Case Manager Utilization Review Nurses 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 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.

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Case Manager Utilization Review Nurse jobs near you
Infographic showing various Case Manager Utilization Review Nurse job openings in Washington as of May 2026, with employment types broken down into 2% As Needed, 87% Full Time, 10% Part Time, and 1% Contract. Highlights an 62% Physical, 1% Hybrid, and 37% Remote job distribution.
Case Manager/ Utilization Reviewer

Case Manager/ Utilization Reviewer

University of Maryland Medical System

Largo, MD • On-site

$40.61 - $60.96/hr

Full-time

Posted 29 days ago

Job description

Job Requirements
Located in Largo in the heart of Prince George's County, our new state-of-the-art regional medical center (University of Maryland Capital Region Medical Center) will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George's County residents.
Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient's need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.
1. Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
2. Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
3. Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.
4. Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
5. Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
6. Conducts HINN discussions/Observation Education.
7. Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
8. Ensures Regulatory Compliance related to Utilization Management conditions of participation.
9. Assures appropriate reimbursement and stewardship of organizational and patient resources.
10. Pursues and reports opportunities to improve reimbursement.
11. Remains current on clinical practice and protocols impacting clinical reimbursement.
Work Experience
Licensure Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
Education Bachelors in Nursing required.
Experience One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
Two years' experience in acute care and four years clinical healthcare experience preferred. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred
Benefits
Benefits
All your information will be kept confidential according to EEO guidelines.
Compensation:
• Pay Range: $40.61-$60.96
• Other Compensation (if applicable):

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