ZipRecruiter

Log In

1

Utilization Management Clinical Reviewer Jobs (NOW HIRING)

Alignment Health

The Utilization Management Clinical Trainer plays a vital role in onboarding and developing ... This position enhances reviewer confidence, ensures peer alignment, and encourages a culture of ...

previous page

Showing results 41-60

All JobsHealthcare JobsNursing JobsNurse Case Manager JobsUtilization Management Clinical Reviewer Jobs

Utilization Management Clinical Reviewer information

See salary details

$31K

$38K

$44K

How much do utilization management clinical reviewer jobs pay per year?

As of Sep 15, 2026, the average yearly pay for utilization management clinical reviewer in the United States is $37,992.00, according to ZipRecruiter salary data. Most workers in this role earn between $34,000.00 and $42,000.00 per year, depending on experience, location, and employer.

What is a utilization management clinical reviewer?

A Utilization Management Clinical Reviewer is a healthcare professional, often a nurse or other licensed clinician, who evaluates medical records and treatment plans to ensure that healthcare services provided to patients are medically necessary, appropriate, and cost-effective. They review clinical documentation against established guidelines and insurance policies, making recommendations or decisions about the approval or denial of coverage for certain procedures or treatments. Their work helps manage healthcare costs while ensuring patients receive adequate care. Utilization Management Clinical Reviewers often serve as a liaison between healthcare providers, insurance companies, and patients.

What are the key skills and qualifications needed to thrive as a utilization management clinical reviewer?

To thrive as a Utilization Management Clinical Reviewer, you need a clinical background such as an RN or LPN license, strong analytical skills, and knowledge of medical necessity criteria. Familiarity with utilization management software, electronic health records (EHRs), and certification in case management (like CCM or URAC) is often required. Attention to detail, critical thinking, and effective communication are vital soft skills for collaborating with healthcare providers and payers. These competencies ensure accurate, evidence-based reviews that support appropriate patient care and regulatory compliance.

What are some common challenges utilization management clinical reviewers face when balancing patient care with cost-effectiveness?

Utilization Management Clinical Reviewers often face the challenge of ensuring patients receive appropriate, evidence-based care while adhering to insurance guidelines and cost-containment measures. Balancing clinical judgment with policy requirements can be complex, especially when cases are borderline or require appeals. Effective communication with healthcare providers and advocating for necessary care, while maintaining compliance, is crucial. Staying updated on changing regulations and clinical guidelines also adds to the complexity of the role.

What is the difference between Utilization Management Clinical Reviewer vs Utilization Review Nurse?

AspectUtilization Management Clinical ReviewerUtilization Review Nurse
CredentialsTypically requires a nursing license (RN) and relevant certificationsRequires an RN license and often additional certifications in utilization review
Work EnvironmentWorks in insurance companies, healthcare organizations, or third-party review firmsEmployed by hospitals, insurance companies, or healthcare facilities
Job FocusEvaluates medical necessity and appropriateness of services for insurance coverageReviews patient care plans and medical records to determine coverage eligibility

Both roles involve nursing expertise and focus on reviewing healthcare services, but the Utilization Management Clinical Reviewer often works in insurance settings assessing medical necessity, while the Utilization Review Nurse may focus more on patient care documentation and hospital-based reviews.

What cities are hiring for Utilization Management Clinical Reviewer jobs?

Cities with the most Utilization Management Clinical Reviewer job openings:

What states have the most Utilization Management Clinical Reviewer jobs?

States with the most job openings for Utilization Management Clinical Reviewer jobs include:

What are popular job titles related to Utilization Management Clinical Reviewer jobs?

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

Infographic showing various Utilization Management Clinical Reviewer job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 13% Part Time, and 2% Contract. Highlights an 83% Physical, 2% Hybrid, and 15% Remote job distribution, with an average salary of $37,992 per year, or $18.3 per hour.

MANAGER OF UTILIZATION REVIEW

Cleveland, OH • On-site

Southwest General
Hospitals • 1 - 5K employees
Learn more about Southwest Generalexternal

Full-time

Posted 13 days ago

Southwest General Health Center rating

6.9

Company rating: 6.9 out of 10

Based on 46 frontline employees who took The Breakroom Quiz

Job description

Summary

  • POSITION INFORMATION
    • Position summary:
      • The Utilization Management (UM) RN Manager is responsible for the day-to-day leadership, operational oversight, and performance management of the Utilization Management nursing team. Reporting to the UM RN Director, the Manager translates department strategy, regulatory and payer requirements, approved clinical review criteria, and organizational priorities into consistent daily execution.
      • The role provides direct supervision, coaching, workflow management, clinical-operational support, and performance oversight for assigned UM staff. The Manager collaborates with physician advisors/medical directors, case management, clinical operations, revenue cycle, payer relations, quality, compliance, and other stakeholders to support timely, accurate, evidence-informed utilization management decisions and appropriate stewardship of healthcare resources.
  • MINIMUM QUALIFICATIONS
    • Education:
      • Bachelor of Science in Nursing (BSN) required, or equivalent qualification consistent with organizational policy.
      • Masters degree in Nursing, Healthcare Administration, Business Administration, Public Health, or a related field preferred.

    • Required length and type of experience:
      • Five or more years of progressive clinical nursing and/or utilization management experience preferred, including three or more years of experience in utilization management, utilization review, case management, managed care, or a closely related function.
      • Prior formal leadership experience required; two or more years of supervisory or management experience preferred.

    • Required licensure, certification or registry:
      • Current Ohio State Board of Nursing license required.
      • Certified Case Manager (CCM) certification preferred.
      • Accredited Case Manager (ACM) certification preferred.
    • Core Knowledge, Skills, and Competencies
      • Knowledge of utilization management and utilization review principles, including prospective, concurrent, and retrospective review.
      • Knowledge of medical necessity, patient status, level-of-care review, authorization processes, payer requirements, denial prevention, and escalation pathways.
      • Knowledge of evidence-based clinical review criteria and appropriate use of clinical decision-support tools.
      • Knowledge of regulatory and accreditation requirements affecting utilization management and clinical review.
      • Demonstrated ability in people leadership, coaching, performance management, conflict resolution, and change management.
      • Demonstrated ability to interpret operational analytics and KPIs, conduct root-cause analysis, and drive process improvement.
      • Demonstrated ability to communicate effectively across interdisciplinary teams, including nursing, physicians, physician advisors, payers, revenue cycle, and leadership.
      • Demonstrated application of professional nursing judgment, ethical practice, confidentiality, and appropriate stewardship of healthcare resources.

What Southwest General Health Center employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply