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Clinical Review Rn Jobs in Illinois (NOW HIRING)

GQR

RN - Case Manager

Mattoon, IL · On-site

$1.9K - $2.0K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Mattoon ... eligible clinicians based on nationally published GSA rates. Actual weekly pay and per diems may ...

GQR Global Markets

RN Case Manager

Mattoon, IL · On-site

$1.9K - $2.0K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Mattoon, Illinois Start Date: September 28, 2026 Profession: Registered Nurse (RN) Facility: Hospital Estimated ...

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Clinical Review Rn information

What is a clinical review RN?

Clinical Review RNs, or Clinical Review Registered Nurses, are licensed nurses who evaluate medical records, treatment plans, and health care documentation to ensure that patient care meets established standards and guidelines. They play a critical role in reviewing the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. Clinical Review RNs often work for insurance companies, hospitals, or healthcare organizations to help with utilization management, case review, and quality assurance. Their expertise helps improve patient outcomes and manage healthcare costs by ensuring the right care is delivered at the right time.

What skills and qualifications are needed to thrive as a clinical review RN?

To thrive as a Clinical Review RN, you need a robust clinical nursing background, strong assessment skills, and an active RN license, often with experience in case management or utilization review. Familiarity with utilization management software, electronic health records, and knowledge of insurance regulations or CMS guidelines is typically required. Excellent communication, critical thinking, and attention to detail help set outstanding Clinical Review RNs apart. These skills ensure accurate clinical evaluations, compliance with regulations, and effective coordination between patients, providers, and payers.

How does a clinical review RN collaborate with other healthcare professionals during the patient care review process?

A Clinical Review RN regularly works with physicians, case managers, social workers, and insurance representatives to assess the medical necessity and appropriateness of patient care plans. They participate in interdisciplinary meetings, provide clinical insights, and help ensure that care decisions align with policies and regulations. This collaboration is key to streamlining the review process, minimizing delays in patient care, and supporting optimal outcomes for both patients and the healthcare organization.

What is the difference between Clinical Review Rn vs Medical Reviewer?

AspectClinical Review RnMedical Reviewer
CredentialsRegistered Nurse (RN) license, clinical experienceMedical degree (MD or DO), specialized training
Work EnvironmentHealthcare facilities, insurance companies, telehealthHospitals, insurance companies, consulting firms
Employer & Industry UsageInsurance, healthcare providers, government agenciesInsurance, legal, healthcare consulting
Primary FocusAssessing medical records, determining coverage eligibilityEvaluating medical cases, providing expert opinions

While both roles involve reviewing medical information, Clinical Review Rns primarily assess insurance claims and medical records as registered nurses, whereas Medical Reviewers are typically physicians with advanced medical training who evaluate complex cases and provide expert opinions. Understanding these differences helps in choosing the right career path or job search focus.

How to become a clinical review RN?

To become a clinical review RN, you typically need to earn a Bachelor of Science in Nursing (BSN) or an associate degree in nursing, pass the NCLEX-RN exam to obtain licensure, and gain clinical experience in healthcare settings. Additional certifications in case management or utilization review can enhance qualifications for this role.

What does a clinical review RN do?

A clinical review RN evaluates medical records, treatment plans, and patient data to determine coverage, appropriateness, and compliance with healthcare policies. They often work for insurance companies or healthcare organizations, requiring strong clinical knowledge, attention to detail, and certification such as a registered nurse license. Their assessments help ensure proper patient care and cost-effective treatment decisions.
Clinical Review Rn jobs near you
Infographic showing various Clinical Review Rn job openings in Illinois as of August 2026, with employment types broken down into 1% As Needed, 86% Full Time, 10% Part Time, 2% Contract, and 1% Nights. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

Case Manager - Utilization Review RN

Chicago, IL

Community First Medical Center
Health Care and Social Assistance • 501 - 1,000 employees
Learn more about Community First Medical Centerexternal

$43.47 - $53/hr

Full-time, Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 12 days ago

Community First Medical Center rating

3.9

Company rating: 3.9 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

1,055th of 1,066 rated hospitals

Job description

Description

Under the general direction of the Director of Behavioral Health, the Case Manager - Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care.

The Case Manager - Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions.


  Community First Medical Center offers benefits to all its full-time and part-time employees:          

  • United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time
  • Met Life Dental and Vision
  • Paid Time Off  (PTO) with annual accruals up to 168 hrs./year
  • Six paid holidays
  • Company Paid Life insurance and Short-term Disability 
  • 401(k) after 90 days
  • Continuing Education reimbursement and 2 days paid off separate from PTO
  • Free Parking Garage
  • Internal Growth Opportunities


Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

QUALIFICATIONS

Education

  • Associate Degree in Nursing required.
  • Bachelor of Science in Nursing (BSN) preferred.  

Experience

  • Minimum three (3) years of acute care nursing experience required.
  • Minimum two (2) years of Case Management and/or Utilization Review experience preferred.
  • Experience with discharge planning, utilization review, denial management, and payer authorization preferred.

Licensure

  • Current Illinois Registered Nurse license required.
  • ACM, CCM, or CMAC certification preferred.

KNOWLEDGE, SKILLS & ABILITIES

  • Knowledge of Medicare, Medicaid, and commercial insurance regulations.
  • Working knowledge of InterQual and/or MCG criteria.
  • Behavioral Health background knowledge
  • Access to Behavioral Health Networks 
  • Understanding of utilization management and care coordination principles.
  • Knowledge of discharge planning and post-acute care resources.
  • Strong analytical and critical thinking skills.
  • Excellent verbal and written communication skills.
  • Ability to prioritize multiple complex patient cases.
  • Ability to build collaborative relationships with physicians and interdisciplinary teams.
  • Computer proficiency and electronic medical record experience.

PERFORMANCE EXPECTATIONS

Success in this role is measured by:

  • Appropriate admission status determination
  • Denial prevention and appeal success
  • Timely discharge planning 
  • Reduction in avoidable days
  • Average Length of Stay management
  • Readmission reduction
  • Documentation compliance
  • Regulatory compliance
  • Patient throughput
  • Patient and physician satisfaction

What Community First Medical Center employees say

Pay

Hours and flexibility

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