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Utilization Management Nurse Consultant Jobs (NOW HIRING)

Intus, Inc

Contract Utilization Management Nurse

$42/hr

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

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

CVS Health

Prior Authorization UM Nurse Consultant

Utilization Management Nurse Consultant (RN) Remote | Prior Authorization | Louisiana Medicaid Preferred Are you an experienced RN with a background in Utilization Management and Prior Authorization?

CVS Health

Prior Authorization UM Nurse Consultant

Utilization Management Nurse Consultant (RN) Remote | Prior Authorization | Utilization Management Are you an experienced RN with utilization management or prior authorization experience looking to ...

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Utilization Management Nurse Consultant information

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$39K

$89.5K

$163K

How much do utilization management nurse consultant jobs pay per year?

As of Sep 7, 2026, the average yearly pay for utilization management nurse consultant 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 does a utilization management nurse consultant do?

A Utilization Management Nurse Consultant is a registered nurse who evaluates the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities. They review patient medical records, coordinate with healthcare providers, and help ensure that care provided aligns with insurance guidelines and clinical standards. Their goal is to promote quality care while managing costs and preventing unnecessary treatments. Utilization Management Nurse Consultants often work for insurance companies, hospitals, or third-party review organizations.

What are the key skills and qualifications needed to thrive as a utilization management nurse consultant?

To thrive as a Utilization Management Nurse Consultant, you need a current RN license, experience in clinical nursing, and a solid understanding of healthcare regulations and medical necessity criteria. Familiarity with utilization review software, electronic health records (EHRs), and guidelines such as InterQual or MCG is typically required. Excellent critical thinking, attention to detail, and effective communication skills help you collaborate with healthcare providers and advocate for appropriate patient care. These skills ensure accurate assessment of medical services, regulatory compliance, and optimal patient outcomes while managing healthcare costs.

What are some common challenges utilization management nurse consultants face when collaborating with healthcare providers and insurance companies?

Utilization Management Nurse Consultants often navigate complex situations where they must balance patient care needs with insurance policies and cost considerations. Challenges can include negotiating medical necessity with physicians, addressing gaps in documentation, and ensuring timely communication between providers and payers. Maintaining a collaborative and diplomatic approach is essential, as the role requires advocating for quality patient outcomes while adhering to regulatory and organizational guidelines. Effective time management and strong communication skills are key to overcoming these challenges and building positive relationships across interdisciplinary teams.

What is the difference between Utilization Management Nurse Consultant vs Utilization Review Nurse?

AspectUtilization Management Nurse ConsultantUtilization Review Nurse
CertificationsRN license, possibly certifications in case management or utilization reviewRN license, certifications in case management or utilization review often preferred
Work EnvironmentCollaborates with healthcare providers, insurance companies, and case managers in clinical review settingsPerforms chart reviews and authorizations mainly within insurance or healthcare organizations
Employer & Industry UsageHospitals, insurance companies, healthcare consulting firmsInsurance companies, managed care organizations, healthcare providers

While both roles involve reviewing patient cases to ensure appropriate care, the Utilization Management Nurse Consultant typically provides expert guidance, policy development, and complex case analysis, whereas the Utilization Review Nurse focuses on performing clinical reviews and authorizations within established protocols.

More about Utilization Management Nurse Consultant jobs

What cities are hiring for Utilization Management Nurse Consultant jobs?

Cities with the most Utilization Management Nurse Consultant job openings:

What states have the most Utilization Management Nurse Consultant jobs?

States with the most job openings for Utilization Management Nurse Consultant jobs include:

What job categories do people searching Utilization Management Nurse Consultant jobs look for?

The top searched job categories for Utilization Management Nurse Consultant jobs are:

Utilization Management Nurse Consultant jobs near you
Infographic showing various Utilization Management Nurse Consultant job openings in the United States as of August 2026, with employment types broken down into 2% As Needed, 82% Full Time, 14% Part Time, and 2% Contract. Highlights an 81% In-person, and 19% Remote job distribution, with an average salary of $89,483 per year, or $43 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted yesterday

Job description

About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
•    Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
•    Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
•    Collaborates with healthcare partners to ensure timely review of services and care.
•    Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
•    Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
•    Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
•    Triages and prioritizes cases and other assigned duties to meet required turnaround times.
•    Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
•    Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
•    Duties as assigned.
Essential Qualifications
•    Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
•    Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
•    Must be able to work independently.
•    Must be detail oriented and have strong organizational and time management skills.
•    Adaptive to a high pace and changing environment- flexibility in assignment.
•    Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
•    Proficient in MCG and CMS criteria sets
•    Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
•    Working knowledge of URAC and NCQA.
•   2+ years’ experience in a UM team within managed care setting.
•   3+ years’ experience in clinical nurse setting preferred.
•   TPA Experience preferred.
 

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