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Medical Review Rn Jobs (NOW HIRING)

Osceola-Medical-Center

WI · On-site

$75 - $105/hr

Pursue Quality Osceola Medical Center is committed to implementing these behavior standards as a ... The Inpatient Utilization Review RN is a key member of the healthcare team responsible for ensuring ...

Mission Hospital

RN - Utilization Review

Tuba City, AZ · On-site

$2.7K/wk

Details Client Name Tuba City Regional Job Type Travel Offering Nursing Profession RN Specialty Utilization Review Job ID 37699865 Job Title RN - Utilization Review Weekly Pay $2772.28 Shift Details ...

Ampcus

Clinical Medical Review Nurse

Baltimore, MD · On-site

Clinical Medical Review Nurse. Location: Baltimore, MD. Purpose: * The Clinical Medical Review ... Licenses/Certifications: * RN - Registered Nurse - State Licensure And/or Compact State Licensure R ...

IPRO

Clinical Reviewer (RN)

Jericho, NY · On-site

$38.46 - $43.27/hr

Clinical Reviewer (RN) As a Clinical Reviewer (RN), you will complete the full spectrum of ... level review, supporting Medical Review Analysts, and Physician Consultants to ensure an ...

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

... the medical record for the medical necessity, intensity of service and severity of illness ... Minimum 3 years RN Utilization Manager working for a Health Plan. * At least 3 years of experience ...

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How much do medical review rn jobs pay per hour?

As of Sep 7, 2026, the average hourly pay for medical review rn in the United States is $44.91, according to ZipRecruiter salary data. Most workers in this role earn between $34.38 and $53.37 per hour, depending on experience, location, and employer.

What is a Medical Review RN?

A Medical Review RN is a registered nurse who specializes in reviewing medical records and claims to ensure they meet established guidelines and standards. These nurses often work for insurance companies, government agencies, or healthcare organizations, evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their role may include determining medical necessity, performing utilization reviews, and supporting appeals or audits. They use their clinical knowledge to interpret complex medical information and collaborate with healthcare providers to support accurate decision-making.

How does a Medical Review RN collaborate with other healthcare professionals during the review process?

A Medical Review RN often works closely with physicians, case managers, and insurance representatives to ensure that medical claims and treatment plans meet regulatory and clinical guidelines. Collaboration may involve participating in interdisciplinary meetings, discussing complex cases, and providing clinical expertise to support utilization management decisions. Effective communication and teamwork are essential, as you'll need to relay findings, request additional information, and sometimes clarify medical necessity with providers. This collaborative environment helps ensure quality care for patients while maintaining compliance with payer policies.

What are the key skills and qualifications needed to thrive as a Medical Review RN, and why are they important?

To thrive as a Medical Review RN, you need a strong clinical background, critical thinking skills, and an active RN license, often supported by experience in case management or utilization review. Familiarity with medical coding, claims management software, and knowledge of regulatory guidelines such as Medicare and Medicaid are typically required. Strong attention to detail, excellent written communication, and the ability to work independently are essential soft skills for this role. These competencies ensure accurate and compliant medical record reviews, which are critical for proper claims adjudication and regulatory adherence.

How to become a medical review RN?

To become a medical review RN, you need to earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Additionally, gaining experience in clinical settings and obtaining certifications such as Certified Professional Coder (CPC) or specialized training in medical review can enhance qualifications for this role.
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Medical Review Rn jobs near you
Infographic showing various Medical Review Rn job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 79% Full Time, 14% Part Time, and 6% Contract. Highlights an 87% Physical, 1% Hybrid, and 12% Remote job distribution, with an average salary of $93,419 per year, or $44.9 per hour.

Inpatient Utilization Review RN - 1.0FTE

Osceola Medical Center

Osceola, WI • On-site

Other

Posted 20 days ago

Job description

Summary:
OMC Core Behavior Standards:
Create Teamwork• Lead with Honesty & Integrity• Convey Compassion• Show Respect• Pursue Quality
Osceola Medical Center is committed to implementing these behavior standards as a foundation for how we hire, develop, and retain our team members. By intentionally selecting candidates whose values and behaviors align with these standards, we ensure that our mission is lived out every day, creating an environment where patients feel valued, respected, and confident that OMC is the place for all their healthcare needs.
Tentative Schedule:
Monday-Friday, Days: 8am-4:30pm
Job Summary:
The Inpatient Utilization Review RN is a key member of the healthcare team responsible for ensuring the appropriate utilization of hospital resources through concurrent review, medical necessity evaluation, payer communication, and regulatory compliance activities. This role collaborates with physicians, nursing staff, case management, and third-party payers to support optimal patient outcomes while ensuring appropriate admission status, level of care, and reimbursement.
The Inpatient Utilization Review RN also assists with care coordination and discharge planning activities to support efficient patient progression throughout the continuum of care.
Responsibilities include:
Utilization Review and Medical Necessity Determination
  • Perform concurrent reviews of inpatient, observation, swing bed, and other applicable patient stays to evaluate medical necessity and appropriate level of care.
  • Apply established criteria to support admission status and continued stay determinations.
  • Collaborate with providers to obtain documentation necessary to support medical necessity and reimbursement.
  • Identify opportunities to improve documentation and ensure accurate patient status designation.
  • Monitor length of stay and identify barriers to timely progression of care.
Payer Authorization and Denial Management
  • Obtain and maintain required payer authorizations for admissions, continued stays, procedures, and post-acute services.
  • Serve as liaison between the hospital, physicians, and insurance providers regarding utilization review activities.
  • Assist in the appeal process for denied services and work collaboratively with interdisciplinary teams to reduce avoidable denials.
  • Maintain current knowledge of payer requirements and reimbursement regulations.
Care Coordination and Discharge Planning
  • Collaborate with patients, families, providers, nursing staff, and community resources to facilitate safe and effective transitions of care.
  • Assist with discharge planning activities including referrals to post-acute services, home health agencies, rehabilitation facilities, and durable medical equipment providers.
  • Identify barriers to discharge and coordinate interventions to support timely patient transitions.
Patient and Family Education
  • Educate patients and families regarding care transitions, insurance requirements, available resources, and post-discharge services.
  • Promote patient understanding and engagement in discharge and follow-up plans.
Documentation and Regulatory Compliance
  • Maintain complete, accurate, and timely documentation in the electronic health record.
  • Ensure compliance with CMS Conditions of Participation, Critical Access Hospital regulations, payer requirements, and organizational policies.
  • Participate in audits, quality improvement initiatives, and regulatory reviews as needed.
  • Track and report utilization review metrics, trends, and opportunities for improvement.
Knowledge, Skills, and Abilities
  • Strong knowledge of utilization review principles, medical necessity criteria, reimbursement methodologies, and regulatory requirements.
  • Understanding of CMS, Medicare, Medicaid, and commercial payer guidelines.
  • Proficiency with electronic health records and Microsoft Office applications.
  • Strong critical thinking, clinical judgment, and analytical skills.
  • Excellent communication, negotiation, and collaboration abilities.
  • Ability to work independently while managing multiple priorities and deadlines.
  • Knowledge of discharge planning and care coordination processes.
Physical Requirements for the Role:
  • Sitting and standing associated with a normal office environment
  • Some bending, stooping, and stretching
  • Able to use office equipment such as copier, computer, telephone and fax machine
  • Able to lift 5-10 lbs frequently, 20 lbs occasionally.
  • Hand dexterity for office machine operation, mobility to complete errands, or sitting for extended periods of time
  • Adequate vision, hearing and speaking abilities to perform essential duties, including telephone communication
  • Able to prioritize activities when faced with competing demands
Qualifications:
  • Graduate of an accredited nursing program.
  • Current Wisconsin Registered Nurse (RN) license required.
  • Bachelor's degree in nursing (BSN) preferred.
  • Minimum of three (3) years of clinical nursing experience in acute care required.
  • Previous experience in utilization review, case management, care coordination, revenue cycle, or discharge planning preferred.
  • Experience working with Medicare, Medicaid, and commercial insurance plans preferred.
  • Familiarity with Critical Access Hospital regulations required.
  • Certified Case Manager (CCM), Accredited Case Manager (ACM), or utilization review certification preferred.
  • 3 years acute care experience

Work Environment:
The Inpatient Utilization Review RN functions in a collaborative clinical and administrative environment requiring frequent interaction with providers, nursing staff, patients, families, payers, and community agencies. Work involves detailed chart review, documentation analysis, payer communication, and interdisciplinary care coordination. The role may require flexible scheduling to meet organizational and patient care needs.
Why Join OMC?
At OMC, we don't just hire for skills-we hire for behaviors that align with our mission. We invest in team members who are committed to making a meaningful difference in the lives of our patients and in the communities we serve.

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