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Outpatient Utilization Management Jobs (NOW HIRING)

IntePros

Utilization Management RN

Philadelphia, PA · On-site

This role is responsible for performing utilization management reviews to determine the medical ... Experience reviewing inpatient, outpatient, or specialty service authorizations. This is an ...

Astiva Health, Inc

UM Nurse Reviewer

Orange, CA · On-site

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

UHS

GROUP DIR - UTILIZATION MANAGEMENT

Jacksonville, FL · On-site

Responsibilities The Director of Utilization Management is responsible for overseeing the Utilization Management Program for the Inpatient, Partial Hospital, Intensive Outpatient, ECT (River Point ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

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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 Management Nurse

Little Rock, AR • On-site

Paladin Consulting
Recruiting and Staffing Services • 1 - 5K employees
Learn more about Paladin Consultingexternal

Other

Posted 5 days ago

Job description

Duties:
Utilization Management:
  • Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.
  • Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
Communication:
  • Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
Compliance:
  • Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
Workflow:
  • Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.
Knowledge:
  • Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
  • Other duties as assigned.
Skills:
  • Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4.
  • Experience in utilization management and/or medical review preferred.
Specialized Knowledge & Skills:
  • Ability to prioritize and make sound nursing judgments through critical thinking
  • Excellent verbal and written communication skills
  • Ability to build collaborative relationships
  • Attention to details
  • Ability to interpret complex documentation
Education:
  • Registered Nurse License, active and unencumbered state license in the state where job duties are performed is required.
  • BSN preferred. 2. Four (4) years of clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.

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