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Utilization Management Nurse Reviewer Jobs (NOW HIRING)

NeueHealth

Utilization Management Nurse - RN

Encino, CA · On-site

Utilization Management Nurse - RN California, United States NeueHealth is a value-driven healthcare ... Responsibilities include reviewing prior authorizations for treatments, medications, procedures ...

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How much do utilization management nurse reviewer jobs pay per hour?

As of Jun 17, 2026, the average hourly pay for utilization management nurse reviewer 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.

How much do utilization review nurses make in the US?

Utilization management nurse reviewers in the US typically earn between $70,000 and $90,000 annually, depending on experience, location, and certifications. Salaries can vary based on healthcare setting and level of responsibility, with some experienced professionals earning over $100,000.

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

To thrive as a Utilization Management Nurse Reviewer, you need a strong clinical background, active RN licensure, and in-depth knowledge of medical necessity criteria and healthcare regulations. Familiarity with utilization management software, electronic health records (EHRs), and decision-support tools like InterQual or Milliman is typically required. Critical thinking, attention to detail, and effective communication are essential soft skills for accurately reviewing cases and collaborating with providers. These skills ensure that patient care is both medically appropriate and cost-effective, supporting quality outcomes and regulatory compliance.

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

A Utilization Management Nurse Reviewer can increase income by taking on additional part-time or freelance review assignments, leveraging certification in case management or related areas, and working flexible hours. Developing specialized skills and obtaining relevant certifications can also qualify for higher-paying opportunities or overtime pay, helping to reach the extra $2000 monthly goal.

How can I become a utilization review nurse?

To become a utilization review nurse, you typically need to hold a registered nurse (RN) license and have experience in clinical nursing or case management. Many employers also require knowledge of healthcare policies, utilization review processes, and sometimes certification such as the Certified Professional in Healthcare Quality (CPHQ) or a similar credential. Strong communication skills and familiarity with electronic health records (EHR) systems are also beneficial.

What are Utilization Management Nurse Reviewers?

Utilization Management Nurse Reviewers are registered nurses who evaluate medical records and treatment plans to determine the medical necessity, appropriateness, and efficiency of healthcare services. They work for insurance companies, hospitals, or managed care organizations to ensure that patients receive appropriate care while controlling costs. Their responsibilities include reviewing clinical documentation, applying evidence-based guidelines, and communicating with healthcare providers about coverage decisions. This role helps balance quality patient care with resource management in the healthcare system.

What are some common challenges faced by Utilization Management Nurse Reviewers and how can they be addressed?

Utilization Management Nurse Reviewers often navigate complex cases where clinical guidelines and insurance policies must be balanced with patient needs, which can be challenging. They may encounter high caseloads, tight deadlines, and frequent communication with providers and payers, requiring strong organizational and negotiation skills. Staying current with evolving regulations and payer criteria is essential. Building effective communication and time-management strategies, as well as leveraging ongoing training, can help address these challenges and ensure quality, timely reviews.

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

AspectUtilization Management Nurse ReviewerUtilization Review Nurse
CertificationsRN license, possibly certifications in case management or utilization reviewRN license, certifications in case management or utilization review
Work EnvironmentInsurance companies, health plans, or managed care organizationsHospitals, clinics, or insurance companies
Employer & Industry UsagePrimarily in managed care and insurance sectorsIn healthcare facilities and insurance sectors

Both roles involve reviewing patient cases to determine medical necessity, but the Utilization Management Nurse Reviewer typically works within insurance or managed care organizations focusing on authorization and coverage decisions. The Utilization Review Nurse may work directly in healthcare settings or insurance, with a broader scope including ongoing patient care assessments. While overlapping in credentials and industry, their primary work environments and specific responsibilities differ slightly.

What does a nurse utilization reviewer do?

A nurse utilization reviewer evaluates medical records and treatment plans to determine the appropriateness and necessity of healthcare services. They ensure that care complies with insurance policies and clinical guidelines, often working with electronic health records and requiring knowledge of coding and documentation standards. This role involves reviewing cases, making recommendations, and supporting cost-effective patient care decisions.
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Utilization Management Nurse Reviewer jobs near you
Utilization Management Nurse (84124)

Utilization Management Nurse (84124)

Regency Integrated Health Services

Austin, TX • Remote

Full-time

Posted yesterday

Job description

Primary Responsibilities

The Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations.

Essential Functions

Perform concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services.

Follow and maintain compliance with CMS requirements, may include after-hours, holiday and weekend coverage.

Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member's health need.

Location Requirements

This position is remote but requires the employee to live within our service area, which can include any of the following areas within Texas: Rio Grande Valley, DFW, greater Austin, greater Houston, greater San Antonio, Coastal Bend, or Laredo.

Educational/Training Requirements

  • Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred. 2+ years of clinical nursing experience.
  • Payor Utilization Management: 3 years recommended experience
  • Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook
  • Proficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria.

Licensing Requirements

  • Current unencumbered LVN or RN license in Texas or compact license.

Experience Requirements

  • 2+ years Utilization management experience with a health insurance company (managed care/payer experience required).
  • UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side. 
  • 5+ years of acute clinical experience.
  • The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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About Regency Integrated Health Services

Sourced by ZipRecruiter

Regency Integrated Health Services, located in Victoria, Texas, U.S., is a healthcare provider operating within post-acute healthcare and rehabilitation industry sector. As a well-known name in the industry with an official website at regencyhealthcare.com, the company specializes in offering a wide range of health services which primarily include skilled nursing, rehabilitation, long-term care, and assisted living services. Since its inception, Regency Integrated Health Services has been committed to providing the highest possible standards in healthcare.

Industry

Health care and social assistance

Company size

201 - 500 Employees

Headquarters location

Victoria, TX, US

Year founded

2015

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