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Utilization Management Nurse Jobs (NOW HIRING)

Intus, Inc

Utilization Management Nurse

$80K - $95K/yr

Role Overview The Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual ...

SIHO Insurance Services, Inc.

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Utilization Management Nurse

Columbus, IN · On-site

Utilization Management Nurse Reports To: Manager of Utilization Management Brief Description of Duties: This position is reserved for a licensed Registered Nurse who will perform the Utilization ...

HealthCheck360

Utilization Management Nurse

Dubuque, IA · On-site

Utilization Management Nurse Location : Onsite in Dubuque, IA. Also accepting remote applicants. We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys ...

Luminis Health

Utilization Management Nurse

Annapolis, MD · On-site

$34 - $55/hr

Monitors and identifies patterns or trends in utilization management; monitors potential and actual ... Bachelor's of Science in Nursing or Associate's degree in Nursing with equivalent experience. BSN ...

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Utilization Management Nurse information

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$39K

$89.5K

$163K

How much do utilization management nurse jobs pay per year?

As of Jul 19, 2026, the average yearly pay for utilization management nurse 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 are some common challenges a Utilization Management Nurse faces when coordinating care between providers and insurance companies?

A Utilization Management Nurse often navigates the challenge of balancing patient advocacy with insurance guidelines, ensuring that care recommendations meet both clinical standards and payer requirements. Communicating complex medical information to both providers and insurance representatives can be demanding, especially when there are disagreements about coverage or medical necessity. Additionally, staying updated on changing policies and maintaining thorough documentation under tight deadlines are frequent aspects of the role. Strong collaboration skills and attention to detail are essential for success in this position.

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

To thrive as a Utilization Management Nurse, you need a registered nursing license, strong clinical judgment, and experience in case management or utilization review. Familiarity with medical management software, InterQual or Milliman guidelines, and insurance authorization processes is typically required. Excellent analytical thinking, communication, and negotiation skills help you coordinate with providers and advocate for patients. These competencies ensure appropriate resource use, compliance with regulations, and optimal patient outcomes.

What does a utilization management nurse do?

A utilization management nurse reviews medical records and treatment plans to determine if healthcare services meet insurance or clinical guidelines for necessity and appropriateness. They collaborate with healthcare providers and insurance companies to approve, modify, or deny coverage, often using electronic health records and adhering to regulatory standards. Certification in case management or utilization review is common in this role.

What is a Utilization Management Nurse?

A Utilization Management Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services provided to patients. They review medical records and treatment plans to ensure that care meets established guidelines and is cost-effective. Utilization Management Nurses work with healthcare providers, insurance companies, and patients to coordinate care and prevent unnecessary procedures or hospitalizations. Their goal is to support high-quality patient care while managing healthcare costs.

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

Utilization Management Nurses can increase their income by taking on additional part-time or per diem shifts, especially in high-demand settings. Developing specialized skills or certifications, such as case management or health informatics, can also qualify them for higher-paying roles or consulting opportunities outside regular hours.

What is the difference between Utilization Management Nurse vs Case Manager?

AspectUtilization Management NurseCase Manager
CredentialsRN license, certifications in utilization reviewRN license, case management certification often preferred
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, community health agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of servicesCoordinating patient care and discharge planning

Utilization Management Nurses primarily focus on reviewing medical necessity and approving healthcare services, while Case Managers coordinate patient care and facilitate discharge planning. Both roles require RN licensure and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.

How to make 150,000 as a nurse?

A Utilization Management Nurse can earn $150,000 by gaining extensive experience, obtaining advanced certifications such as CCM or ANCC, and working in high-paying settings like insurance companies or specialty healthcare organizations. Developing strong analytical skills and understanding healthcare policies can also enhance earning potential, often requiring a master's degree or specialized training. Salary varies based on location, employer, and level of expertise.

What Does a Utilization Management Nurse Do?

A utilization management nurse ensures that healthcare services are administered appropriately. Their job responsibilities include working in a hospital, health practice, or other clinical setting reviewing patient clinical records, drafting clinical appeals, and overseeing staff members. The qualifications for a utilization management nurse include a nursing degree and a registered nursing license. Most people in this job also have career experience in case management and utilization review.

How to get into utilization management as a nurse?

To become a utilization management nurse, candidates typically need a registered nurse (RN) license and experience in clinical settings. Additional certifications such as Certified Professional in Healthcare Quality (CPHQ) or case management credentials can improve job prospects, and strong knowledge of healthcare policies and documentation is essential.
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Utilization Management Nurse jobs near you
Infographic showing various Utilization Management Nurse job openings in the United States as of July 2026, with employment types broken down into 5% As Needed, 80% Full Time, 10% Part Time, and 5% Contract. Highlights an 75% In-person, and 25% Remote job distribution, with an average salary of $89,483 per year, or $43 per hour.
Utilization Management Nurse

Utilization Management Nurse

Intus, Inc

Remote

$80K - $95K/yr

Full-time

Medical, Dental, Vision

Re-posted 11 hours ago

Job description

About IntusCare
IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. IntusCare empowers teams to take control of their operations and improve outcomes for dual-eligible seniors - some of the most socially vulnerable and clinically complex individuals in the US healthcare system.
Role Overview
The Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care decisions and support timely, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management Nurse ensures services are medically necessary, aligned with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program integrity, improving participant outcomes and supporting the delivery of coordinated, value-based care.
Responsibilities
  • Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are:
    • Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.
    • In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.
  • Active involvement in various aspects of the utilization management process, including:
    • Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.
    • Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.
    • Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.
  • Employ effective use of knowledge, critical thinking, and skills to:
    • Advocate quality care and enhanced quality of life
    • Advocate decreased hospital stay when appropriate
    • Maintain accurate records of all patient related interactions
  • Appeal Management - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider appeals process. Responsibilities Include:
    • Comprehensive review of provider network appeals.
    • Collaboration with the PACE Program's Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the PACE program policies.

Qualifications
  • 3 to 5 years of utilization management experience.
  • Current RN license
  • Proven experience working in risk based integrated models of care.
  • Ability to use data to drive decisions and collaboration with internal and external stakeholders.
  • Strong strategic thinking, problem solving, and decision making skills.
  • Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

What We Offer
  • A chance to be a part of a trailblazing team in healthcare technology.
  • Competitive salary and equity package.
  • Comprehensive benefits including health, dental, and vision insurance.
  • A collaborative, inclusive, and dynamic work environment.
  • Opportunities for professional growth and development

Compensation: The salary range for this role is $80K-$95K. We expect the ideal candidate to fall near the midpoint of this range, though final compensation will be determined based on experience, skills, and organizational needs.
Work location: This is a fully remote role based in the United States.
Sponsorship: This position is not eligible for sponsorship.

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