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Rn Utilization Management Jobs (NOW HIRING)

Guthrie

RN - Utilization Management - FT

Binghamton, NY · On-site

Up To $25,000 Sign On Bonus For Qualified RNs! Summary The Registered Nurse (RN) Utilization Management (UM) in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices ...

New

University of Rochester

$81K - $109K/yr

Utilization Management experience preferred KNOWLEDGE, SKILLS AND ABILITIES * Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred LICENSES AND CERTIFICATIONS * RN - ...

CVS Health

Utilization Management Nurse Consultant

$29.10 - $62.32/hr

Registered Nurse (RN) - Utilization Management (24/7 Operations) Step away from bedside care and make a system-wide impact. Join our Utilization Management team and help ensure members receive the ...

Sanford Health

RN Utilization Management

Fargo, ND · On-site

Currently holds an unencumbered RN license with the State Board of Nursing where the practice of ... Case Management (CCM), or holds a certification in their patient population specialty that they ...

CVS Health

Utilization Management Nurse Consultant

$29.10 - $62.32/hr

Registered Nurse (RN) - Utilization Management (24/7 Operations) Leverage your clinical expertise to make a broader impact. Join our Utilization Management team and help ensure members receive the ...

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How much do rn utilization management jobs pay per year?

As of Jul 14, 2026, the average yearly pay for rn 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.

How does an RN Utilization Management professional typically collaborate with physicians and other healthcare team members?

RN Utilization Management professionals work closely with physicians, case managers, and insurance representatives to ensure patients receive appropriate, high-quality care while managing healthcare costs. They review patient records, communicate clinical findings, and may participate in interdisciplinary meetings to discuss care plans and discharge needs. Building strong relationships and maintaining open lines of communication with the care team is essential for timely authorizations and effective care coordination. This collaborative approach helps optimize patient outcomes and resource utilization.

How to make $150,000 as a nurse?

Registered nurses in utilization management can reach a $150,000 salary by gaining specialized certifications, such as Certified Case Manager (CCM), and accumulating several years of experience in the field. Working in high-demand healthcare settings, taking on leadership roles, or pursuing advanced education like a master's degree can also increase earning potential.

What does a utilization management RN do?

A utilization management RN reviews medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They collaborate with healthcare providers and insurance companies to ensure patient care aligns with guidelines and policies, often using electronic health records and clinical criteria. Certification in case management or utilization review is common in this role.

What are the key skills and qualifications needed to thrive as an RN Utilization Management Nurse, and why are they important?

To thrive as an RN Utilization Management Nurse, you need a current RN license, strong clinical assessment skills, and experience in care coordination or case management. Familiarity with utilization review tools, electronic health records, and knowledge of insurance guidelines or InterQual/MCG criteria are typically required. Exceptional communication, critical thinking, and negotiation skills help facilitate collaboration among providers, payers, and patients. These abilities are crucial for ensuring appropriate resource use, compliance with regulations, and optimal patient outcomes.

How to get into utilization management as an RN?

To become an RN in utilization management, you typically need a valid nursing license and experience in clinical settings. Gaining knowledge of insurance policies, healthcare regulations, and utilization review processes is important, and some employers prefer or require certification such as the Certified Professional in Healthcare Quality (CPHQ) or Certified Utilization Review Professional (CURP). Developing strong analytical, communication, and documentation skills can also improve job prospects in this field.

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

AspectRn Utilization ManagementRn Case Management
CertificationsRN license, possibly certifications in utilization reviewRN license, case management certification often preferred
Work EnvironmentUtilization review departments, insurance companies, hospitalsCommunity clinics, hospitals, insurance companies
Primary FocusReviewing medical necessity and appropriateness of servicesCoordinating patient care and discharge planning

Both roles require an RN license, but Rn Utilization Management focuses on reviewing the necessity of services, while Rn Case Management emphasizes coordinating patient care. Understanding these differences helps professionals choose the right career path and employers.

How to make an extra $2000 a month as a nurse?

Rn Utilization Management professionals can increase income by taking on overtime, working per diem shifts, or pursuing additional certifications such as case management or insurance review. Some also supplement income through consulting, remote case reviews, or part-time roles in telehealth, leveraging their clinical expertise and utilization review skills.

What are RN Utilization Management nurses?

RN Utilization Management nurses are registered nurses who specialize in reviewing healthcare services to ensure patients receive appropriate and cost-effective care. They evaluate the necessity, efficiency, and quality of medical treatments and procedures, often working with insurance companies, hospitals, or healthcare organizations. Their responsibilities include reviewing patient records, coordinating with clinical staff, making coverage recommendations, and ensuring compliance with healthcare regulations. This role helps manage healthcare costs while maintaining high standards of patient care.
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Rn Utilization Management jobs near you
RN Utilization Mgmt Full-Time Day

RN Utilization Mgmt Full-Time Day

MLK Community Healthcare

Los Angeles, CA • On-site

Full-time

Medical

Re-posted 24 days ago

Job description

POSITION SUMMARY
The RN Utilization Management (RN UM) functions as a support liaisons for a variety of UM functions which may include: the e-TAR process, denials management, and the UM process. Coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
RN Utilization Management staff may work as assigned in one of the following assignments: ETARS management and/or denials management as well as routine UM functions (insurance authorizations, clinical reviews, and liaison) :
  1. Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
  2. Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
  3. Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
  4. Reports e-TAR support progress and delays to Manager or Director of care management.
  5. Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
  6. Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
  7. Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
  8. Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
  9. Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
  10. Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
  11. Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
  12. Patient needs are supported within the limitations of the existing individual beneficiary care structure.
  13. Communicates relevant elements of the health plan benefits.
  14. Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
  15. Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
  16. Adheres to the Care Management Department policies and procedures.
  17. Participates in the Quality and Performance Improvement Plan for the Care Management Department.
  18. Considers the patient population served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
  19. Collaborates with on-site care management team to support best practice guidelines.
  20. Attends unit/department staff meetings as well as other meetings as assigned.
  21. Maintain and complete Compass program training as assigned.
  22. Other duties may be assigned such as denials management and appeals in lieu of other UM duties.

POSITION REQUIREMENTS
A. Education
  • Associates Degree in Nursing required. BSN preferred.

B. Qualifications/Experience
  • Minimum 3-5 years recent experience in Case Management or Utilization Management or Prior Authorization
  • Current California Registered Nurse License. Certification in UM or CM is highly preferred
  • Experience in MCG and/or Interqual required A team player that can follow a system and protocol to achieve a common goal
  • Highly organized and well developed oral and written communication skills
  • Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills

C. Special Skills/Knowledge
  • Bilingual language skills preferred (Spanish) Basic computer skills
  • Current Basic Life Support (BLS)
  • CCM Certification preferred

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