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Senior Nurse Practitioner Utilization Review Jobs

Fusion HCR

Utilization Review Nurse

Las Vegas, NV · On-site

Direct Hire - Utilization Review Nurse, this is an onsite position, working with our client in Acute Care. Overview Seeking an experienced Utilization Review Nurse (RN) to review patient admissions ...

Cynet Health

Utilization Review

Eureka, CA · On-site

$1.9K/wk

Details Client Name Providence Health and Services Job Type Travel Offering Nursing Profession Registered Nurse Specialty Utilization Review Job ID 18635671 Job Title Utilization Review Weekly Pay ...

CommonSpirit Health

Utilization Review Nurse

Job Summary and Responsibilities As our Utilization Review Nurse, you will ensure the medical necessity and appropriateness of care for all hospitalized patients, promoting fiscal responsibility and ...

Oscar Health

Utilization Review Nurse

Dallas, TX · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role: You will perform frequent case reviews, check medical records and speak with care providers regarding ...

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How much do senior nurse practitioner utilization review jobs pay per hour?

As of Aug 8, 2026, the average hourly pay for senior nurse practitioner utilization review 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 does a senior nurse practitioner utilization review do?

A Senior Nurse Practitioner Utilization Review is responsible for evaluating medical records and treatment plans to ensure that healthcare services provided to patients are medically necessary, appropriate, and efficient. They use clinical expertise to review cases, collaborate with physicians and insurance companies, and help determine the level of care required. This role also involves identifying potential areas for improvement in patient care and contributing to policy development to enhance healthcare quality and resource management.

What are the key skills and qualifications needed to thrive as a senior nurse practitioner utilization review, and why are they important?

To excel as a Senior Nurse Practitioner Utilization Review, you need advanced clinical expertise, a graduate nursing degree (MSN or DNP), active NP licensure, and experience in case management or utilization review. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of payer guidelines and regulatory standards like CMS are typically required. Strong analytical thinking, communication, and negotiation skills help in decision-making and collaborating with healthcare teams and insurance providers. These competencies ensure appropriate resource utilization, compliance, and optimal patient outcomes while balancing cost-effectiveness and care quality.

How does a senior nurse practitioner utilization review typically collaborate with physicians and other healthcare professionals?

Senior Nurse Practitioners in Utilization Review frequently work in multidisciplinary teams, collaborating closely with physicians, case managers, and insurance representatives. They review patient records, assess the medical necessity of treatments, and communicate recommendations or decisions to ensure alignment with clinical guidelines. Building strong working relationships and maintaining clear, professional communication is essential, as these interactions help streamline care delivery, resolve discrepancies, and advocate for optimal patient outcomes.

What is the difference between Senior Nurse Practitioner Utilization Review vs Nurse Practitioner Utilization Review?

AspectSenior Nurse Practitioner Utilization ReviewNurse Practitioner Utilization Review
CredentialsMaster's or Doctorate in Nursing, Nurse Practitioner license, Certification in Utilization ReviewMaster's or Doctorate in Nursing, Nurse Practitioner license, Certification in Utilization Review
Work EnvironmentHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare organizations
ResponsibilitiesOversees utilization review processes, mentors staff, handles complex casesPerforms utilization reviews, assesses patient necessity, documents findings

Both roles require advanced nursing credentials and certification in utilization review. The senior role typically involves leadership, oversight, and handling complex cases, while the standard Nurse Practitioner Utilization Review focuses on performing reviews and documentation. The roles are often found in similar healthcare settings and serve complementary functions within utilization management.

What cities are hiring for Senior Nurse Practitioner Utilization Review jobs? Cities with the most Senior Nurse Practitioner Utilization Review job openings:
What are the most commonly searched types of Nurse Practitioner Utilization Review jobs? The most popular types of Nurse Practitioner Utilization Review jobs are:
What states have the most Senior Nurse Practitioner Utilization Review jobs? States with the most job openings for Senior Nurse Practitioner Utilization Review jobs include:
Senior Nurse Practitioner Utilization Review jobs near you

Utilization Review Nurse

Maniilaq Association

Kotzebue, AK • On-site

Other

Posted 5 days ago

Job description

Maniilaq Association is a P.L. 93-638 Native/Indian Preference/EEO Employer
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Utilization Review Nurse Job Code: 2026:OTZ-201 Location: Kotzebue, Alaska Program: Nursing Division FT/PT Status: Full Time Job Responsibilities:
MANIILAQ ASSOCIATION
5/2026
Title: Utilization Management Nurse Pay Grade: 31
Program: Nursing Status: Exempt
Housing Priority: 3 Covered: Yes
POSITION SUMMARY
The Utilization Management Nurse (UMN) is responsible for performing Utilization Review and managing risk, coordinates and facilitates with departmental staff on Durable Medical Equipment (DME), and pharmacy prior authorizations. THE UMN works with the medical treatment and case management team in the coordination of patient care including the development of new operational changes and new services to ensure compliance and risk mitigation. The UMN will use a process that includes screening and case finding, comprehensive multidimensional assessment, connection with available resources, implementation of the plan and ongoing monitoring and re-assessment/follow-up. The UMN assists with the Quality and Case Management programs and, coordinates the IPC4 program. This position reports directly to the Chief Nursing Officer or designee.
PRINCIPAL DUTIES AND RESPONSIBILITIES
  1. Coordinates the IPC4 process in Medicare/Medicaid and private insurances.
  2. Assists in revenue procurement by:making sure insurance approvals are completed correctly with no penalty; helping to identify alternate resources of funding such as VA, Denali Kid Care, Medicare, and Medicaid; and monitoring the appeal process when claims are denied.
  3. Chairs Quarterly Utilization Review Committee meetings to improve utilization of resources and improve patient care.
  4. Submits Quarterly reports to CMO and CNO for Board of Director meetings.
  5. Works closely with Coders and Billers to insure accurate, timely billing information.
  6. Completes Utilization Review processes as assigned.
  7. Oversees development and maintenance of a resource database of Federal, State, community, and institutional resources.
  8. Assists in arranging team conferences and networks for relationship building and resource development with village leaders, Community Health Aides/Practitioners, MHC Medical Staff, MHC Nursing Staff, private insurance contacts, Medicaid/Medicare contacts, ANMC Providers, and the CM/SC/UR Team.
  9. Participates on improvement projects as assigned.
  10. Participates in Medicaid Task Force committee through Alaska Native Health Board.
  11. Completes Quality Improvement, Quality Assurance and Performance Improvement projects and tasks as assigned.
  12. Utilizes team building, problem solving skills and lean principles in the on-going quality improvement initiatives.
  13. Identify, assess, and monitor potential clinical, operational, and compliance risks within the Utilization Review and Case Management programs.
  14. Report and document incidents, near-misses, and adverse events in accordance with organizational policy and regulatory standards.
  15. Participate in root cause analyses and collaborate with leadership to implement corrective action plans to mitigate future risks.
  16. Collaborate with the Risk Management team to review, update, and communicate policies and procedures relevant to utilization review and patient care coordination.
  17. Educate clinical and administrative staff on risk awareness, safety protocols, and compliance requirements.
  18. Coordinate and facilitate prior authorizations for DME by collaborating with patients, clinical staff and providers to ensure clients' needs are met.
  19. Collaborate with providers and pharmacist process prior authorizations for specialized high-cost medications; monitor appeal process if claims are denied.
Job Qualifications:
MINIMUM REQUIREMENTS
Current licensure as a RN with at least two years of Case Management, Utilization Review, Discharge Planning or Quality Improvement experience preferred. Knowledge of acute and chronic illnesses, specialty clinic procedures, and community health nursing. Must be able to pass the core competencies assigned to this position and maintain the educational requirements of the program. Ability to utilize various computer programs, including Cerner and Microsoft Office. Demonstrates a wide theory base in order to interact in an effective manner with physicians, health team members, community agencies, and clients/families with diverse opinions, values, and religious and cultural ideals. Ability to work autonomously with little direction and be directly accountable for practice. Knowledge of and experience working with all regulatory, state, and federal agencies.
Other Job Information (if applicable):
DISCLAIMER
The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be considered an exhaustive list of all responsibilities, duties and skills required of personnel in this job, and the employer reserves the right to revise or change this description. This description does not constitute a written or implied contract of employment. To perform this job successfully, an individual must be able to satisfactorily perform each of the above essential duties and meet physical demands. Reasonable accommodations may be made to enable individuals with disabilities to meet those conditions.

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