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Outpatient Utilization Management Jobs (NOW HIRING)

US Tech Solutions

Utilization Review Nurse

Canton, MA · On-site

$55 - $60/hr

Perform outpatient utilization management (UM) and medical necessity reviews for prior authorization and precertification requests. * Review clinical documentation and determine benefit eligibility ...

Appworks

Utilization Management Registered Nurse

Utilization Management Registered Nurse (UM RN) We're seeking a dedicated and detail-oriented ... In this role, you'll perform both inpatient and outpatient utilization reviews while supporting ...

Talanto

$80 - $100/hr

Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization 6,890 - 8,038 $ Important: if an employer asks you to log into their system via iCloud or Google, send a code, an SMS ...

Devoted

$80 - $100/hr

As a Clinical Guide on our Outpatient Utilization Management team, you'll have the opportunity to make a difference in the lives of our members. You'll be responsible for clinical review of ...

Mass General Brigham Incorporated

$100 - $125/hr

Expertise in clinical inpatient and outpatient utilization management reviews utilizing InterQual ® , company policies and procedures, and other resources as determined by review, including ...

Medix

Director of Utilization Management

Manhattan, NY · On-site

$109.15 - $151.44/hr

Experience with both inpatient and outpatient utilization management, including medical and pharmacy utilization. * Experience with appeal reviews. * NY Market Experience. Skills * Strong ability to ...

UHS

Director Utilization Management

Plymouth, IN · On-site

Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ... utilization management for both mental health and substance abuse behavioral health disorders.

UHS

Director Utilization Management

Plymouth, IN · On-site

Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory ... utilization management for both mental health and substance abuse behavioral health disorders.

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Outpatient Utilization Management information

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$39K

$89.5K

$163K

How much do outpatient utilization management jobs pay per year?

As of Sep 9, 2026, the average yearly pay for outpatient utilization management in the United States is $89,483.00, according to ZipRecruiter salary data. Most workers in this role earn between $64,500.00 and $104,500.00 per year, depending on experience, location, and employer.

What is outpatient utilization management?

Outpatient utilization management is a healthcare process focused on ensuring that patients receive appropriate, efficient, and cost-effective care in outpatient settings. Professionals in this field review medical services, coordinate care, and assess treatment plans to confirm they meet established guidelines and medical necessity. Their goal is to optimize patient outcomes while managing healthcare resources responsibly. This often involves collaboration with healthcare providers, insurance companies, and patients to facilitate the best possible care outside of hospital admissions.

What are the key skills and qualifications needed to thrive in outpatient utilization management?

To thrive in Outpatient Utilization Management, you need a background in nursing or healthcare, strong knowledge of medical necessity criteria, and familiarity with insurance guidelines, typically supported by RN licensure or a related healthcare degree. Experience with utilization management software, electronic health records (EHRs), and familiarity with CMS or Milliman guidelines is often required. Strong analytical, communication, and collaboration skills help professionals effectively advocate for patients while coordinating across clinical and administrative teams. These skills are crucial to ensure appropriate care authorization, optimize resource use, and support quality patient outcomes in outpatient settings.

What are some common challenges faced in outpatient utilization management, and how can they be addressed?

Professionals in Outpatient Utilization Management often face challenges such as balancing cost-effectiveness with quality patient care and navigating complex insurance policies. Managing high caseloads and ensuring timely authorization for services can also be demanding. Addressing these challenges requires strong communication skills, up-to-date knowledge of payer guidelines, and effective collaboration with providers and interdisciplinary teams. Many organizations offer ongoing training and support to help team members stay current and manage workflow efficiently.

What is the difference between Outpatient Utilization Management vs Outpatient Case Management?

AspectOutpatient Utilization ManagementOutpatient Case Management
Primary FocusReviewing medical necessity and authorizations for outpatient servicesCoordinating ongoing patient care and discharge planning
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, clinics, outpatient facilities, community health programs
CredentialsTypically requires healthcare background, certifications like URAC or CCMOften requires nursing, social work, or case management certifications

While both roles involve outpatient healthcare, Outpatient Utilization Management primarily focuses on reviewing and authorizing services to ensure medical necessity, whereas Outpatient Case Management emphasizes coordinating patient care and discharge planning. Understanding these differences helps clarify career paths and employer expectations in outpatient healthcare settings.

Is outpatient utilization management a growing field?

Outpatient utilization management is a growing field due to increasing demand for cost-effective healthcare and emphasis on outpatient services. Professionals in this area often use data analysis and care coordination skills, with certifications like URAC or AAPC enhancing job prospects.

What are popular job titles related to Outpatient Utilization Management jobs?

For Outpatient Utilization Management jobs, the most frequently searched job titles are:

Utilization Review Nurse

Canton, MA • On-site

US Tech Solutions
IT Services • 1 - 5K employees
Learn more about US Tech Solutionsexternal

$55 - $60/hr

Other

Re-posted 2 days ago

Job description

$55-$60 per hour

Canton, MA

Contract

Duration: 6 Month Contract (Possibility of Extension)

Position Overview

We are seeking an experienced Utilization Management (UM) Registered Nurse to support outpatient utilization review and prior authorization activities for a leading healthcare organization. The ideal candidate will have a strong background in managed care, utilization management, medical necessity review, prior authorization, and outpatient clinical review.

This role is responsible for reviewing medical records, evaluating the medical necessity of requested services using established clinical guidelines, collaborating with physicians and healthcare providers, and ensuring timely authorization decisions while maintaining compliance with regulatory standards.

Key Responsibilities

  • Perform outpatient utilization management (UM) and medical necessity reviews for prior authorization and precertification requests.

  • Review clinical documentation and determine benefit eligibility using evidence-based clinical guidelines and health plan policies.

  • Evaluate requests for outpatient procedures, surgeries, imaging, therapies, specialty medications, and other healthcare services.

  • Ensure all utilization review activities meet regulatory turnaround time requirements.

  • Collaborate with Medical Directors for complex cases, denial recommendations, and clinical escalations.

  • Communicate authorization decisions with physicians, provider offices, hospitals, and healthcare facilities.

  • Participate in appeal reviews and provide clinical recommendations when appropriate.

  • Maintain accurate documentation within utilization management systems.

  • Monitor cases for quality, compliance, and adherence to organizational policies.

  • Identify opportunities for process improvement and contribute to quality initiatives.

  • Serve as a clinical resource for internal teams regarding utilization management guidelines and medical necessity criteria.

Required Qualifications

  • Active, unrestricted Registered Nurse (RN) license.

  • Associate Degree in Nursing (ADN) required.

  • Minimum 5 years of RN clinical experience.

  • Minimum 3-5 years of Utilization Management (UM), Case Management, Prior Authorization, or Medical Management experience.

  • Previous Managed Care, Health Plan, Medicare, Medicaid, or Commercial Insurance experience.

  • Strong knowledge of:

  • Utilization Management (UM)

  • Medical Necessity Review

  • Prior Authorization

  • Precertification

  • InterQual and/or MCG Guidelines

  • Experience reviewing outpatient clinical services.

  • Excellent clinical assessment and critical thinking skills.

  • Strong communication skills with providers and interdisciplinary teams.

  • Ability to work independently in a remote environment.

  • Comfortable using multiple systems while managing a high-volume workload.

Preferred Qualifications

  • BSN preferred.

  • Experience with outpatient utilization management.

  • Experience using InterQual and/or MCG clinical criteria.

  • Experience with Medicare Advantage or Commercial Health Plans.

  • Previous experience with appeals, grievances, or denial reviews.

  • Knowledge of NCQA, CMS, and utilization management regulatory requirements.

Note:

  • Candidates can be remote but must have an active unrestricted Massachusetts RN License

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.

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About US Tech Solutions

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US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

Industry

It services

Company size

1,001 - 5,000 Employees

Headquarters location

Jersey City, NJ, US

Year founded

2000

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