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Milliman Care Guidelines Jobs (NOW HIRING)

One Brooklyn Health

Case Management Nurse

Brooklyn, NY · On-site

$64.74/hr

Knowledge of Milliman Care Guidelines * Knowledge of CMS guidelines for post-acute plaements * Communicate with Attending Physicians on admission guidelines * Provide real time interventions to ...

Mercy

Care Manager

Joplin, MO · On-site

Including neonatal/infant, child, adolescent, adult, and geriatric adult patients. 6. Knowledge of InterQual or Milliman Care Guidelines preferred. Why Mercy? From day one, Mercy offers outstanding ...

Mercy

Including neonatal/infant, child, adolescent, adult, and geriatric adult patients. 6. Knowledge of InterQual or Milliman Care Guidelines preferred. Why Mercy? From day one, Mercy offers outstanding ...

Mercor

Utilisation Management Expert - RN

New York, NY · Remote

$100 - $150/hr

Conduct and oversee clinical reviews against InterQual , MCG , or Milliman care guidelines to support admission and level-of-care determinations. * Manage the physician advisor program to support ...

Calvert Health System

APPEALS COORDINATOR

Prince Frederick, MD · On-site

$23 - $28.75/hr

The Appeals Coordinator will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG) or InterQual guidelines, determine the viability of the appeal, and manage the ...

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How much do milliman care guidelines jobs pay per hour?

As of Jul 30, 2026, the average hourly pay for milliman care guidelines in the United States is $36.13, according to ZipRecruiter salary data. Most workers in this role earn between $18.03 and $44.95 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Milliman Care Guidelines Specialist, and why are they important?

To thrive as a Milliman Care Guidelines Specialist, you need strong clinical knowledge, experience in healthcare utilization management, and familiarity with evidence-based care criteria, often supported by a nursing or healthcare degree. Proficiency in using the MCG (formerly Milliman Care Guidelines) software, electronic medical records (EMRs), and relevant healthcare IT systems is essential. Attention to detail, analytical thinking, and effective communication are important soft skills for success in this role. These skills ensure accurate application of clinical guidelines, promote effective care decisions, and support compliance with regulatory standards.

What are Milliman Care Guidelines?

Milliman Care Guidelines, also known as MCG, are evidence-based clinical guidelines used by healthcare providers and insurers to make informed decisions about patient care. These guidelines help standardize treatment protocols, determine the medical necessity of services, and support care management processes. By using MCG, organizations aim to ensure that patients receive appropriate, efficient, and effective care while managing healthcare costs. The guidelines are regularly updated to reflect the latest medical research and best practices.

How does working with Milliman Care Guidelines involve collaboration with other healthcare professionals?

Professionals working with Milliman Care Guidelines often collaborate closely with clinicians, case managers, utilization review teams, and IT specialists to ensure evidence-based care recommendations are accurately implemented. This teamwork helps to align clinical decisions with best practices, improve patient outcomes, and streamline workflows. Regular interdisciplinary meetings, training sessions, and feedback loops are common, fostering a supportive environment where collective expertise leads to better healthcare delivery.

What is the difference between Milliman Care Guidelines vs Utilization Review Nurse?

AspectMilliman Care GuidelinesUtilization Review Nurse
CredentialsTypically requires clinical nursing licensure and familiarity with guidelinesRegistered Nurse (RN) license, often with additional certifications
Work EnvironmentUsed by healthcare organizations for care management and policy developmentPerforms patient chart reviews, assesses medical necessity, and makes utilization decisions
Industry UsageDeveloped by Milliman for healthcare quality and utilization managementEmployed by hospitals, insurance companies, and healthcare providers

While Milliman Care Guidelines are standardized protocols used to guide clinical decision-making, Utilization Review Nurses apply these guidelines in real-time patient assessments to determine the necessity and appropriateness of care. Both play vital roles in healthcare quality management, but one provides the framework, and the other executes the review process.

More about Milliman Care Guidelines jobs
What states have the most Milliman Care Guidelines jobs? States with the most job openings for Milliman Care Guidelines jobs include:
What job categories do people searching Milliman Care Guidelines jobs look for? The top searched job categories for Milliman Care Guidelines jobs are:
Milliman Care Guidelines jobs near you
Infographic showing various Milliman Care Guidelines job openings in the United States as of July 2026, with employment types broken down into 83% Full Time, 11% Part Time, and 6% Contract. Highlights an 61% In-person, 6% Hybrid, and 33% Remote job distribution, with an average salary of $75,144 per year, or $36.1 per hour.

Nurse Case Manager, Utilization Management

1199SEIU Funds

Manhattan, NY

Full-time

Re-posted 19 days ago

Job description


Responsibilities
Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach
Performs medical necessity review that includes concurrent, prospective, retrospective reviews and 1st level appeals, to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and vendor contracts.
Apply Milliman Care Guidelines, internal Policies and Reference Guides to determine appropriateness of services/equipment that require Prior Authorization
Maintain accurate records of all patient/provider/vendor related interactions in designated medical management system
Apply clinical guidelines, provide recommendations and discuss cases with Medical Consultants
Meet timelines and quality standards related to Utilization Management
Maintain and submit reports and logs on reviewed activities as outlined by the UM program operational procedures,
Identify and participate in quality improvement activities as it relates to internal programs, processes studies and projects
Authorize vendor services using clinically proven criteria to make consistent care decisions
Maintain compliance with all state mandated regulations
Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services
Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations
Perform additional duties and projects as assigned by management


Qualifications
Bachelor's degree Valid New York State Registered Nurse (RN) required
Minimum three (3) years Medical/Surgical experience plus a minimum of two (2) years Utilization Management experience required
BSN and Certification in Case Management a plus
Proficient in application and use of industry standard Utilization Management criteria (Milliman Care Guidelines), Medicare and coverage guidelines, health claims processing, medical coding
Excellent verbal and written communication skills, problem-solving, clinical assessment, care planning skills, and independent decision-making capability
Computer and organizational skills required, ability to manage competing priorities, multi-task with results-oriented outcomes and work in a fast paced environment. Intermediate skills of Microsoft Office systems preferred.

Employment Type: Full time

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