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Rn Utilization Review Nurse Jobs (NOW HIRING)

UofL Health

RN Utilization Review

Louisville, KY · On-site

Position Summary and Purpose The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management ...

Netsmart

Utilization Review Nurse

Responsible for utilization review work for emergency admissions and continued stay reviews ... Current and unrestricted RN license * At least 3 years clinical experience in acute care setting in ...

Uoflhealth

RN Utilization Review

Louisville, KY · On-site

Position Summary and Purpose The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management ...

UofL Health

RN Utilization Review

Louisville, KY · On-site

Position Summary and Purpose The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management ...

Umpqua Health

Utilization Review Nurse

$85K - $105K/yr

Utilization Review Nurse Remote Ability to travel on-site to 3031 NE Stephens St., Roseburg OR ... Active, unrestricted RN license (BSN or MSN) in Oregon or a compact state * Graduation from an ...

Ascension

Registered Nurse Utilization Review

Baltimore, MD · On-site

$84K - $120K/yr

Utilization Management Schedule: Day-Shift | Full-Time | Monday-Friday 8:00AM-4:30PM | Weekend ... Registered Nurse credentialed from the Maryland Board of Nursing obtained prior to hire date or job ...

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How much do rn utilization review nurse jobs pay per hour?

As of Aug 27, 2026, the average hourly pay for rn utilization review nurse 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 an RN Utilization Review Nurse?

An RN Utilization Review Nurse evaluates patient care to ensure medical services are necessary, efficient, and compliant with healthcare regulations. They review medical records, collaborate with healthcare providers, and assess treatment plans to optimize patient outcomes while managing costs. These nurses often work for hospitals, insurance companies, or healthcare organizations, ensuring appropriate resource utilization. Their role helps prevent unnecessary procedures and supports quality patient care.

What does an RN Utilization Review Nurse do?

A typical day for an RN Utilization Review Nurse involves reviewing patient medical records to determine the medical necessity of hospital admissions or ongoing care, communicating with physicians, case managers, and insurance representatives, and documenting decisions in electronic health record systems. You will often spend a significant amount of time on critical assessments, phone or email correspondence, and ensuring compliance with regulatory and insurance guidelines. The work is generally office-based or remote, and you may collaborate closely with both clinical and administrative staff. This structured environment allows you to leverage your clinical background while supporting cost-effective, high-quality patient care.

What are the key skills and qualifications needed to thrive as an RN Utilization Review Nurse?

To thrive as an RN Utilization Review Nurse, a current RN license, strong clinical knowledge, and experience with healthcare regulations and insurance guidelines are essential. Familiarity with medical review software, EHR systems, and utilization management platforms—as well as certification such as CCM (Certified Case Manager)—is often required. Strong analytical thinking, attention to detail, and effective communication with interdisciplinary teams set outstanding candidates apart. These skills ensure accurate care assessments, compliance with insurance requirements, and effective coordination between providers, patients, and payers.

How to get into utilization review as a registered nurse?

To become a utilization review nurse, registered nurses typically need clinical experience and knowledge of healthcare policies. Earning certifications such as the Certified Professional in Healthcare Quality (CPHQ) or Utilization Review Certification (URC) can improve job prospects. Familiarity with medical records, insurance processes, and strong communication skills are also important for success in this role.
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Rn Utilization Review Nurse jobs near you
Infographic showing various Rn Utilization Review Nurse 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, 3% Contract, and 1% Nights. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Case Manager, RN- Utilization Review

Tampa General Hospital (TGH)

Tampa, FL • On-site

Full-time

This job post has expired 8 days ago. Applications are no longer accepted.

Tampa General Hospital rating

7.3

Company rating: 7.3 out of 10

Based on 162 frontline employees who took The Breakroom Quiz

388th of 1,064 rated hospitals

Job description

Under the general supervision of the Utilization Management Manager and in accordance with established policies, professional guidelines, and CMS Conditions of Participation for Utilization Review, the Utilization Management Nurse (UMN) ensures patients are assigned to the most appropriate level of care based on nationally recognized admission and continued stay criteria. The UMN performs admission, concurrent, and retrospective utilization reviews using clinical expertise and medical necessity screening tools; evaluates appropriateness of services and expected length of stay; and supports timely authorization determinations through collaboration with payers. The UMN works closely with physicians, Care Coordinators, Resource Center Associates, Nursing, and leadership to address cases where criteria are not met, escalate concerns to the Physician Advisor or appropriate medical leadership, participate in denial management, and support efficient patient flow. All duties are performed in alignment with Tampa General Hospital's mission, vision, values, and quality standards.
Technical Knowledge, Skills, and Abilitie
  • In-depth knowledge of utilization review processes, nationally recognized medical necessity criteria (e.g., InterQual or similar), and appropriate level-of-care determination.
  • Ability to apply clinical nursing knowledge to evaluate the appropriateness of admissions, continued stays, diagnostic testing, and treatment plans.
  • Knowledge of Medicare, Medicaid, managed care, and commercial payer requirements, including authorization, denial, and appeal processes.
  • Ability to identify cases where criteria are not met, analyze complex clinical and payer-specific issues, and escalate appropriately through physician, Physician Advisor, and leadership channels.
  • Strong communication skills with the ability to effectively collaborate with physicians, payers, interdisciplinary teams, and leadership to justify medical necessity, resolve denials, and support patient flow.
  • Proficiency in accurate, timely documentation of utilization reviews, payer communications, and determinations using electronic medical records and utilization management systems.

Essential Function
  • Conducts initial admission reviews using nationally accepted criteria to determine medical necessity, appropriate level of care, and patient status designation.
  • Performs concurrent and ongoing reviews to assess continued stay, appropriateness of services, and expected length of stay, ensuring alignment with clinical presentation and regulatory requirements.
  • Reviews retrospective cases and participates in denial management, including preparation of clinical documentation and support for appeals in collaboration with Physician Advisors and Appeals teams, when appropriate.
  • Collaborates with payers regarding medical necessity determinations, authorization decisions, and continued stay reviews for inpatient admissions and clinical services.
  • Identifies cases where admission or continued stay criteria are not met and communicates findings with the attending physician, escalating to the Physician Advisor or appropriate medical leadership as needed.
  • Works closely with Care Coordinators, Resource Center Associates, Nursing, Physicians, and leadership to support appropriate patient status, care progression, and effective utilization of hospital resources.
  • Promotes appropriate status designation and medical necessity decisions to support timely patient movement and efficient hospital throughput.
  • Documents all utilization reviews, payer interactions, authorization decisions, clinical findings, and determinations in accordance with departmental standards, regulatory requirements, and organizational policies.
  • Contributes to departmental and organizational performance improvement initiatives related to utilization management, denial reduction, regulatory compliance, and quality outcomes.
  • Performs all duties in accordance with CMS Conditions of Participation, hospital utilization review plans, confidentiality standards, and professional nursing and utilization management guidelines.
  • Proficiency in Microsoft applications, including Outlook, Teams, Word, and Excel, to support clinical documentation, communication, data tracking, reporting, and interdisciplinary collaboration in a remote or hybrid work environment.

Qualifications
  • Licensed as a Registered Nurse in the state of Florida
  • Three (3) years as a practicing RN.
  • Utilization Management experience preferred

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About Tampa General Hospital

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Tampa General Hospital was named the #1 hospital in Tampa Bay by U.S. News & World Report, 2020-2021, and recognized as one of America's Best Hospital's in five medical specialties: Cardiology & Heart Surgery, Diabetes & Endocrinology, Gastroenterology & GI Surgery, Nephrology, and Orthopedics. Tampa General Hospital has been designated a Magnet Hospital by the American Nurses Credentialing Center (ANCC), the highest recognition for nursing excellence, for the fourth consecutive time - an accomplishment that fewer than one percent of hospitals nationwide have earned. TGH is accredited by The Joint Commission and was awarded disease-specific certification in five medical specialties. TGH is also accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). *Air transport provided by Metro Aviation, Inc.

Industry

Hospitals

Company size

5,001 - 10,000 Employees

Headquarters location

Tampa, FL, US

Year founded

1927

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