Las Vegas, NV · On-site
Utilization review criteria (InterQual/Milliman), Medicare/Medicaid guidelines * Chart review and clinical documentation analysis * Regulatory compliance and hospital standards * Strong communication ...
Quick apply
Las Vegas, NV · On-site
Utilization review criteria (InterQual/Milliman), Medicare/Medicaid guidelines * Chart review and clinical documentation analysis * Regulatory compliance and hospital standards * Strong communication ...
Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines ... Experience Proven experience in utilization review or utilization management within hospital or ...
Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines ... Experience Proven experience in utilization review or utilization management within hospital or ...
Tulsa, OK · On-site
The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to limit possible recoupment from third party pay sources including Medicare, Medicaid, HMO or private ...
Tulsa, OK · On-site
The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to limit possible recoupment from third party pay sources including Medicare, Medicaid, HMO or private ...
The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to limit possible recoupment from third party pay sources including Medicare, Medicaid, HMO or private ...
The Utilization Review Specialist asses, plans, implements and evaluates the internal processes to limit possible recoupment from third party pay sources including Medicare, Medicaid, HMO or private ...
Las Vegas, NV · On-site
$41 - $60/hr
- Utilization Review Nurse Position Summary The Utilization Review Nurse is responsible for reviewing ... Ensure compliance with Medicare, Medicaid, commercial insurance, and regulatory requirements.
Quick apply
Las Vegas, NV · On-site
$41 - $60/hr
- Utilization Review Nurse Position Summary The Utilization Review Nurse is responsible for reviewing ... Ensure compliance with Medicare, Medicaid, commercial insurance, and regulatory requirements.
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
Knowledge of Medicare, Medicaid, and Managed Care requirements * Progressive knowledge of community ... utilization. * Reviews H&Ps and admitting orders of all direct, transfer, and emergency care ...
Knowledge of Medicare, Medicaid, and Managed Care requirements * Progressive knowledge of community ... utilization. * Reviews H&Ps and admitting orders of all direct, transfer, and emergency care ...
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
Quick apply
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
... Utilization Review Committee * Facilitate timely discharges, transfers, and recertifications when ... Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and ...
... Utilization Review Committee * Facilitate timely discharges, transfers, and recertifications when ... Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and ...
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
Utilization Review Specialist Job Summary: The Utilization Review (UR) Specialist is responsible ... Experience working with commercial insurance, Medicaid, and/or Medicare preferred * Familiarity ...
... Utilization Review Committee * Facilitate timely discharges, transfers, and recertifications when ... Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and ...
... Utilization Review Committee * Facilitate timely discharges, transfers, and recertifications when ... Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and ...
Torrance, CA · On-site
$57/hr
Job Title: RN - Utilization Review (Remote) Location: Remote - Must work in Pacific Standard Time ... Interpret and apply Medicare rules and documentation (e.g., CC44s, ABNs, HINNs, MCSNs) * Rotate ...
Quick apply
Torrance, CA · On-site
$57/hr
Job Title: RN - Utilization Review (Remote) Location: Remote - Must work in Pacific Standard Time ... Interpret and apply Medicare rules and documentation (e.g., CC44s, ABNs, HINNs, MCSNs) * Rotate ...
Summary The Utilization Review Nurse screens medical records in accordance with contractual ... Issues required Medicare/Medicaid notifications of medical necessity changes to patients while ...
Summary The Utilization Review Nurse screens medical records in accordance with contractual ... Issues required Medicare/Medicaid notifications of medical necessity changes to patients while ...
New Orleans, LA · On-site
The Utilization Review Nurse ensures appropriate utilization of health services by performing ... Demonstrates a solid understanding of managed care, Medicare, and Medicaid regulations. * Schedule:
New Orleans, LA · On-site
The Utilization Review Nurse ensures appropriate utilization of health services by performing ... Demonstrates a solid understanding of managed care, Medicare, and Medicaid regulations. * Schedule:
Miami, FL · On-site
Utilization Review Nurse Job Summary The Utilization Nurse is responsible for conducting ... Adheres to CMS, state Medicaid, Medicare Advantage, NCQA/URAC, and internal policy requirements ...
Miami, FL · On-site
Utilization Review Nurse Job Summary The Utilization Nurse is responsible for conducting ... Adheres to CMS, state Medicaid, Medicare Advantage, NCQA/URAC, and internal policy requirements ...
The Utilization Review Nurse ensures appropriate utilization of health services by performing ... Demonstrates a solid understanding of managed care, Medicare, and Medicaid regulations. * Schedule:
The Utilization Review Nurse ensures appropriate utilization of health services by performing ... Demonstrates a solid understanding of managed care, Medicare, and Medicaid regulations. * Schedule:
Utilization Review Nurse Job Summary The Utilization Nurse is responsible for conducting ... Adheres to CMS, state Medicaid, Medicare Advantage, NCQA/URAC, and internal policy requirements ...
Utilization Review Nurse Job Summary The Utilization Nurse is responsible for conducting ... Adheres to CMS, state Medicaid, Medicare Advantage, NCQA/URAC, and internal policy requirements ...
Las Vegas, NV · On-site
Interquel or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies and procedures; Joint Commission Accredited Health care Organizations standards, state statutes ...
Quick apply
Las Vegas, NV · On-site
Interquel or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies and procedures; Joint Commission Accredited Health care Organizations standards, state statutes ...
Madera, CA · On-site
This includes those who may have Medicare, Medicaid, HMO or private insurance to cover their stay ... Utilization review procedures include those stated for discharge planning in addition to knowledge ...
Quick apply
Madera, CA · On-site
This includes those who may have Medicare, Medicaid, HMO or private insurance to cover their stay ... Utilization review procedures include those stated for discharge planning in addition to knowledge ...
Madera, CA · On-site
$55.34 - $66.41/hr
This includes those who may have Medicare, Medicaid, HMO or private insurance to cover their stay ... Utilization review procedures include those stated for discharge planning in addition to knowledge ...
Madera, CA · On-site
$55.34 - $66.41/hr
This includes those who may have Medicare, Medicaid, HMO or private insurance to cover their stay ... Utilization review procedures include those stated for discharge planning in addition to knowledge ...
$21.39 - $25.72
2% of jobs
$25.72 - $30.05
9% of jobs
$33.01 is the 25th percentile. Wages below this are outliers.
$30.05 - $34.38
21% of jobs
The median wage is $37.88 / hr.
$34.38 - $38.70
23% of jobs
$38.70 - $43.03
13% of jobs
$46.39 is the 75th percentile. Wages above this are outliers.
$43.03 - $47.36
10% of jobs
$47.36 - $51.68
8% of jobs
$51.68 - $56.01
5% of jobs
$56.01 - $60.34
5% of jobs
$60.34 - $64.66
2% of jobs
$64.66 - $68.99
2% of jobs
$21
$42
$68
In a Medicare Utilization Review role, your day-to-day tasks often include reviewing patient medical records to ensure services meet Medicare coverage criteria, evaluating the necessity and efficiency of proposed treatments, and communicating findings with healthcare providers. You’ll also submit detailed reports, coordinate with physicians, case managers, and insurance representatives, and follow up on documentation requests. Frequently, you’ll participate in interdisciplinary team meetings to discuss patient care plans and recommend alternative treatments if needed. This role requires balancing regulatory compliance with effective healthcare delivery, making each day dynamic and rewarding.
To thrive as a Medicare Utilization Review professional, you need a solid background in healthcare (often as an RN or LPN), strong analytical skills, and familiarity with Medicare regulations and guidelines. Experience using utilization management software, electronic health records (EHRs), and claim review systems like InterQual or MCG is typically required. Strong attention to detail, effective communication, and negotiation skills help set candidates apart. These competencies are crucial to ensure compliance, promote accurate claims processing, and support optimal patient care decisions within Medicare standards.
A Medicare Utilization Review job involves evaluating healthcare services to ensure they meet Medicare guidelines for medical necessity, cost-effectiveness, and quality of care. Professionals in this role review patient records, treatment plans, and insurance claims to determine appropriate coverage and prevent fraud or overutilization. They work closely with healthcare providers and insurance companies to ensure compliance with federal regulations. This role helps maintain the integrity of Medicare services while optimizing patient care and cost efficiency. Strong analytical skills and knowledge of medical coding, billing, and Medicare policies are essential for success in this position.
Full-time
Posted 16 days ago
Utilization Review Nurse (RN)
Las Vegas, NV | Full-Time
Salary: $40 $63/hour
Position Summary
Reviews patient admissions for medical necessity, appropriate resource utilization, and compliance with payer guidelines. Analyzes medical records to ensure care meets established clinical and regulatory standards.
Requirements:
Education/Experience:
Licensure:
Additional Requirements:
Key Skills & Knowledge
Work Environment
