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Clinical Utilization Review Jobs (NOW HIRING)

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Utilization Review Specialist - Exact Billing Solutions (EBS) Lauderdale Lakes, FL - On-site - No ... Review and analyze clinical records, including received documentation from payors, to ensure ...

Peak Health

Clinical Utilization Management Pharmacist

$121K - $144K/yr

Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals ...

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Utilization Review Specialist - Exact Billing Solutions (EBS) Lauderdale Lakes, FL - On-site - No ... Review and analyze clinical records, including received documentation from payors, to ensure ...

Fusion HCR

Utilization Review Nurse

Las Vegas, NV · On-site

This role works closely with clinical teams to ensure efficient resource utilization and quality patient outcomes. Responsibilities * Review admissions using InterQual and/or Milliman criteria

Fusion HCR

Utilization Review Nurse

Las Vegas, NV

This role works closely with clinical teams to ensure efficient resource utilization and quality patient outcomes. Responsibilities * Review admissions using InterQual and/or Milliman criteria

Midland Health

Nurse Utilization Review

Midland, TX

The utilization review (UR) nurse serves to maximize the quality and cost efficiency of health care ... The UR nurse will rely on their clinical judgment, honed over years in acute care settings, to make ...

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Utilization Review Specialist - Exact Billing Solutions (EBS) Lauderdale Lakes, FL - On-site - No ... Review and analyze clinical records, including received documentation from payors, to ensure ...

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How much do clinical utilization review jobs pay per hour?

As of Jun 8, 2026, the average hourly pay for clinical utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Clinical Utilization Review specialist, and why are they important?

To thrive as a Clinical Utilization Review specialist, you need a strong background in nursing or healthcare, knowledge of medical terminology, and often an RN or relevant clinical license. Familiarity with utilization management software, healthcare regulations, and medical coding systems such as ICD-10 and CPT is typically required. Analytical thinking, attention to detail, and strong communication skills help professionals collaborate with care teams and explain decisions clearly. These competencies ensure effective review of medical necessity, regulatory compliance, and optimized patient care outcomes.

What are some common challenges faced by Clinical Utilization Review professionals, and how can they be addressed?

Clinical Utilization Review professionals often face challenges such as balancing the need for cost-effective care with ensuring patients receive appropriate services, managing tight deadlines, and navigating complex insurance requirements. Effective communication with healthcare providers and payers is crucial, as is staying up-to-date with regulatory guidelines. Developing strong organizational skills and maintaining a collaborative approach with interdisciplinary teams can help address these challenges and support successful case outcomes.

What is clinical utilization review?

Clinical utilization review is a process in healthcare that evaluates the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. Utilization review professionals assess patient records and treatment plans to ensure that care provided is medically necessary and aligns with established guidelines. This process helps control healthcare costs, improves quality of care, and ensures compliance with insurance or regulatory requirements. Utilization review can be done prospectively, concurrently, or retrospectively, depending on the stage of patient care.

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

AspectClinical Utilization ReviewMedical Reviewer
CredentialsRN, LPN, or other healthcare professionals with clinical licensesLicensed physicians, often MDs or DOs
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, insurance companies, or healthcare organizations
Primary FocusAssessing medical necessity and appropriateness of careProviding expert medical opinions and final review decisions
Common UsageInvolved in reviewing cases for insurance authorizationMaking clinical determinations on coverage and treatment

While both roles involve reviewing medical cases, Clinical Utilization Review professionals focus on evaluating the necessity of care based on clinical guidelines, often working within insurance or healthcare organizations. Medical Reviewers, typically licensed physicians, provide expert medical opinions and make final coverage decisions. Both roles require healthcare credentials and aim to ensure appropriate patient care and cost management, but their scope and responsibilities differ slightly.

More about Clinical Utilization Review jobs
What cities are hiring for Clinical Utilization Review jobs? Cities with the most Clinical Utilization Review job openings:
What states have the most Clinical Utilization Review jobs? States with the most job openings for Clinical Utilization Review jobs include:
What job categories do people searching Clinical Utilization Review jobs look for? The top searched job categories for Clinical Utilization Review jobs are:
Clinical Utilization Review jobs near you
Infographic showing various Clinical Utilization Review job openings in the United States as of May 2026, with employment types broken down into 6% Locum Tenens, 17% As Needed, 60% Full Time, 6% Part Time, and 11% Contract. Highlights an 89% Physical, 2% Hybrid, and 9% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Clinical Utilization Review RN

Clinical Utilization Review RN

Huntsville Memorial Hospital

Huntsville, TX • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 13 days ago

Job description

Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.
ESSENTIAL JOB FUNCTIONS
Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.
  • Performs initial, concurrent, discharge and retrospective reviews.
  • Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services.
  • Assesses patient needs; Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients
  • Identifies, escalates and resolves complex cases or issues as required.
  • Reviews medical records to verify that the content supports an appropriate level of care (inpatient, observation, bedded outpatients) or type of service.
  • Alerts and collaborates with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria.
  • Coordinates with necessary parties when there are potential or actual denials. Facilitates appeals or the delivery of appeal instructions when denials occur.
  • Facilitates authorization process for admissions and continued stays.
  • Uses knowledge of nursing process and pathophysiology to anticipate discharge needs. May participate in discharge planning through discussions with the care team as needed.
  • Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.
  • Provides support to complex cases or escalations within scope of licensure or refers them to appropriate leadership.
  • Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
  • Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.
  • Abide by HMH Legal Compliance Code of Conduct.
  • Proactively monitors hospital admissions for medical necessity and appropriate hospitalization status utilizing hospital approved criteria.
  • Maintains patient confidentiality and appropriate handling of PHI.
  • Maintains a safe work environment and reports safety concerns appropriately.
  • Performs all other related duties as assigned.

LATITUDE, CONTACTS/INTERACTIONS
All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.
Requirements
Education: Graduate of a school of professional nursing or vocational nursing.
Experience: Must have a minimum of 2 years Acute Care Hospital Utilization Review experience utilizing MCG or Interqual guidelines. ER/ICU background and/or Case Management experience is a plus. Experience should include reviewing for medical necessity/severity of illness for initial hospitalization as well as continuous stay reviews. Experience with Electronic Health Records, Microsoft Excel/Word, and Google Sheets is preferred.
Licensure/Certification: Current licensure as a Registered Nurse in the state of Texas. Certification with the Fellowship of American Academy of Case Managers (FAACM) preferred.
Required Skills: Must have strong analytical, data management, organizational and time management skills. Must have knowledge of applicable federal and state regulatory requirements including: TDI, CMS, & HHSC. This role requires excellent computer and verbal skills as you will be interacting with payers, physicians and other clinical staff. M-F with weekend rotation.
PHYSICAL DEMANDS AND WORKING CONDITIONS
Frequent: sitting, standing, walking, & reaching.
Occasional: lifting, carrying, bending, & squatting,
Visual and hearing acuity required. Work is inside, with good ventilation and comfortable temperature.
Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.
Benefits
  • Health Care Plan (Medical, Dental & Vision)
  • Retirement Plan (401k, IRA)
  • Life Insurance (Basic, Voluntary & AD&D)
  • Paid Time Off
  • Short Term & Long Term Disability
  • Training & Development
  • Wellness Resources

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