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Medicare Utilization Review Jobs (NOW HIRING)

Village Care

Utilization Review Nurse

Manhattan, NY · On-site

$95K - $105K/yr

RN- Utilization Review Nurse Inpatient *Hybrid* Must reside within the New York Tri-State Area - N ... Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and ...

AbsoluteCare

Utilization Review Nurse

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:

Seh

Summary The Utilization Review Nurse screens medical records in accordance with contractual ... Issues required Medicare/Medicaid notifications of medical necessity changes to patients while ...

Saint Rose Hospital

RN - Utilization Review

Hayward, CA · On-site

$2.6K/wk

Utilization review, care coordination, acute hospital, ER/ICU, audits, data abstraction, quality ... Centers for Medicare and Medicaid Services, Continued Stay Reviews, Data Abstraction, Data ...

Southeast Health

Utilization Review Nurse

Dothan, AL · On-site

Summary The Utilization Review Nurse screens medical records in accordance with contractual ... Issues required Medicare/Medicaid notifications of medical necessity changes to patients while ...

Houston Methodist

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 ...

Umpqua Health

Utilization Review Specialist

Winston, OR · On-site

$41K - $47K/yr

Utilization Review Specialist HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR ... Medicare/Medicaid) PREFERRED QUALIFICATIONS * 1+ years of experience in healthcare, managed care ...

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Medicare Utilization Review information

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How much do medicare utilization review jobs pay per hour?

As of Jul 1, 2026, the average hourly pay for medicare 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 typical daily responsibilities of someone working in Medicare Utilization Review?

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.

What are the key skills and qualifications needed to thrive in the Medicare Utilization Review position, and why are they important?

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.

What is a Medicare Utilization Review job?

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.

More about Medicare Utilization Review jobs
What cities are hiring for Medicare Utilization Review jobs? Cities with the most Medicare Utilization Review job openings:
What states have the most Medicare Utilization Review jobs? States with the most job openings for Medicare Utilization Review jobs include:
What job categories do people searching Medicare Utilization Review jobs look for? The top searched job categories for Medicare Utilization Review jobs are:
Medicare Utilization Review jobs near you
Infographic showing various Medicare Utilization Review job openings in the United States as of June 2026, with employment types broken down into 1% As Needed, 94% Full Time, 2% Part Time, 1% Temporary, 1% Contract, and 1% Nights. Highlights an 90% Physical, 2% Hybrid, and 8% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Registered Nurse - Utilization Review

Trinityhealth

Mishawaka, IN • On-site

Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 12 days ago

Job description

Employment Type:Part timeShift:Rotating ShiftDescription:This is a remote position but will need onsite training in Mishawaka Indiana.
Shift: PRN/Days - 8 hr shift
Considering local candidates only!!!
Why Choose Saint Joseph Health System?

  • At Saint Joseph Health System, our values guide every decision we make. Even when challenges arise, we remain committed to our mission: caring for every person who needs us. We invest in our people, our technology, and our capabilities so we can continue delivering exceptional, compassionate care to our communities.

What We Offer

  • Tuition reimbursement for all full-time and part-time colleagues starting on day one

  • Comprehensive benefits beginning day one (Medical, Dental, Vision, PTO, Life Insurance, STD/LTD, and more)

  • Retirement savings plan with employer match

  • Generous paid time off program plus 7 paid holidays

  • No mandatory overtime

  • Employee referral incentive program

  • Access to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environment

What You Will Do
  • Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
  • Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
  • Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
  • Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
  • Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
  • Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
  • Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
  • Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
  • Maintain accurate records, compile reports, and support utilization review program operations
  • Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
  • Support compliance with all regulatory, accreditation, and organizational standards
  • Participate in committee meetings and assist in development of utilization review plans and processes
What You Will Need
  • Graduate of an accredited Registered Nurse (RN) program; Bachelor's Degree in Nursing preferred
  • Active RN license (state-specific requirement applies)
  • Minimum of 2 years of acute care nursing experience
  • Prior utilization review, case management, or payer review experience preferred
  • Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
  • Solid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operations
  • Excellent communication skills with the ability to collaborate effectively across teams
  • Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
  • Proficiency in computer systems and Microsoft Office applications
  • Ability to manage multiple priorities in a fast-paced healthcare environment
  • Flexibility to adapt to changing schedules, workflows, and departmental needs

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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