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Medicare Utilization Review Jobs (NOW HIRING)

Actalent

Utilization Review Nurse

Houston, TX · On-site

$30 - $40/hr

Job Title: RN Clinical Review Nurse (Utilization Review Nurse) The Clinical Review Clinician for ... Knowledge of NCQA, Medicare, and Medicaid regulations. * Knowledge of utilization management ...

Albany Medical Center

Utilization Review Nurse

Albany, NY · On-site

$77K - $119K/yr

... utilization review identifies areas for clinical documentation improvement and contacts appropriate ... Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Med ...

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How much do medicare utilization review jobs pay per hour?

As of Sep 3, 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 is a Medicare Utilization Review?

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.

What does a Medicare Utilization Review do?

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 Medicare Utilization Review?

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.

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Medicare Utilization Review jobs near you
Infographic showing various Medicare Utilization Review job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, and 3% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Registered Nurse

Prairie Lakes Healthcare System

Watertown, SD • On-site

Full-time, Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 19 days ago

Prairie Lakes Healthcare System rating

4.0

Company rating: 4.0 out of 10

Based on 7 frontline employees who took The Breakroom Quiz

Job description

Utilization Review Registered Nurse
Job Summary
Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones
POSITION SUMMARY
Wage: 28.09-44.81
On-site.
This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.
RESPONSIBILITIES
Develops and implements effective utilization review functions resulting in maintaining an average length of stay that is financially justified for hospital operations.
Reviews all inpatient and observation admissions within 24 hours for appropriateness based on approved criteria and standards, Monday through Friday. All weekend admissions are reviewed on the following Monday.
Contacts physicians as required for information to justify admission or continued stay the same day of questionable stay.
Refers all cases where necessity for admission is questionable or potential for denial is identified to the attending physician or his/her designee for appropriate action after notifying the Discharge Planning/Social Services manager.
Develops and maintains a system to monitor and review certification completion.
Maintains complete and accurate documentation which reflects the status of hospital utilization, numbers and categories of cases reviewed, and denials by fiscal intermediaries. Documents and reports back follow-up.
Reviews and follows through the appeal process for patient stay denials.
Other duties may be assigned.
JOB SPECIFICATIONS
Education and/or Experience
Bachelor's degree required.
Five years of acute health care experience.
Two years experience related to utilization review preferred.
Certificates, Licenses, Registrations
Holds or is eligible for current nursing licensor in the State of South Dakota.
Mandatory Basic and Advanced Life Support Training per policy
Benefits
Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.
Additional benefits for those qualifying include:
  • Flexible Spending Account
  • Employee Assistance Program for mental health
  • Education Loan Program
  • Community discounts including the Prairie Lakes Wellness Center

Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.

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