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Utilization Management Nurse Jobs in Virginia (NOW HIRING)

UHS

Director of Utilization Management

Danville, VA · On-site

$79K - $95K/yr

Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, or LCP in Virginia required. EEO Statement All UHS subsidiaries are committed to providing an ...

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

$60 - $80/hr

Coordinates, performs, and monitors all utilization review/management activities of the hospital to ... nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each ...

Sentara Health Plans

UTILIZATION REVIEW NURSE

Norfolk, VA · On-site

$65 - $85/hr

The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical ...

New

Summit BHC

Utilization Specialist

Williamsburg, VA · On-site

Coordinates, performs, and monitors all utilization review/management activities of the hospital to ... nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each ...

Summit BHC

Utilization Specialist - Acute

Williamsburg, VA · On-site

$24 - $28/hr

Coordinates, performs, and monitors all utilization review/management activities of the hospital to ... Education/Requirements: • Graduation from an approved/accredited school of nursing or a Bachelor ...

UHS

Director of Utilization Management

Danville, VA · On-site

Three to five years of experience in utilization review and case management. RN, LCSW, LPC, LMFT, or LCP in Virginia required. EEO Statement All UHS subsidiaries are committed to providing an ...

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All JobsUtilization Management Nurse JobsUtilization Management Nurse Jobs in Virginia

Utilization Management Nurse information

See Virginia salary details

$38.7K

$88.7K

$161.6K

How much do utilization management nurse jobs pay per year?

As of Sep 4, 2026, the average yearly pay for utilization management nurse in Virginia is $88,715.00, according to ZipRecruiter salary data. Most workers in this role earn between $63,900.00 and $103,600.00 per year, depending on experience, location, and employer.

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.

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.

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

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 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 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.

More about Utilization Management Nurse jobs

What are the most commonly searched types of Utilization Management Nurse jobs in Virginia?

The most popular types of Utilization Management Nurse jobs in Virginia are:

What are popular job titles related to Utilization Management Nurse jobs in Virginia?

For Utilization Management Nurse jobs in Virginia, the most frequently searched job titles are:

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

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

What cities in Virginia are hiring for Utilization Management Nurse jobs?

Cities in Virginia with the most Utilization Management Nurse job openings:

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Utilization Management Nurse jobs near you
Infographic showing various Utilization Management Nurse job openings in Virginia as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 15% Part Time, and 2% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution, with an average salary of $88,715 per year, or $42.7 per hour.

Senior Consultant - Clinical Utilization Management SME

Tria Federal

Arlington, VA • On-site

Other

Medical, Life

Posted yesterday

New

Job description

Who we are:

Tria Federal delivers digital services and technology solutions that support the health and safety of veterans, service members and civilians. For two decades, federal agencies have relied on Tria companies to advance their critical missions and modernize their systems, so that they can uphold their commitment to the American people. Today, we are pushing the boundaries of possibility through partnerships and investments in artificial intelligence and emerging technologies, developing solutions for the biggest challenges that government will face tomorrow.

We are proud to employ and support military veterans who bring mission-first mindset, technical expertise, and leadership qualities that strengthen our work. Veterans, transitioning service members, and military spouses are strongly encouraged to apply.

Tria Federal is seeking a Senior Consultant - Clinical Utilization Management SME to provide clinical and utilization-management expertise supporting the Department of Veterans Affairs. The SME will apply utilization-management expertise to assess clinical processes, medical-necessity workflows, referral and authorization processes, care coordination, utilization patterns, and clinical risk.

The ideal candidate is a licensed RN (or other clinical degree / license) with significant experience in utilization management, care management, prior authorization, clinical review, medical necessity, appeals, care coordination, or payer/provider clinical operations.

Responsibilities:
  • Provide clinical subject matter expertise in utilization management, care management, medical necessity, and clinical review.
  • Assess referral, authorization, utilization-management, and care-coordination workflows and identify barriers to timely care.
  • Review clinical and operational processes for opportunities to improve access, quality, appropriateness, cost, and patient outcomes.
  • Evaluate utilization trends and identify clinical, operational, and process drivers of variation.
  • Support development and refinement of clinical workflows, protocols, decision support, and standard operating procedures.
  • Conduct clinical root-cause analysis involving access, utilization, care coordination, denials, medical documentation, and patient-care impacts.
  • Support evaluation of utilization-management practices across providers.
  • Develop clinical recommendations and executive-level analyses that clearly articulate patient-care, operational, financial, and compliance impacts.
  • Collaborate with physicians, nurses, healthcare administrators, network teams, payment SMEs, and VA stakeholders.
  • Support clinical requirements development, operational readiness, implementation, training, and change-management activities.
  • Contribute to assessments, white papers, decision papers, risk analyses, and performance frameworks.
Skills & Experience:
  • 7+ years of healthcare clinical operations, utilization management, care management, case management, clinical review, or related experience.
  • 3+ years of direct utilization-management or clinical review experience preferred.
  • Experience with medical necessity review, prior authorization, concurrent review, retrospective review, appeals, or care management.
  • Understanding of healthcare payer/provider workflows and clinical documentation.
  • Ability to translate clinical findings into operational and executive recommendations.
  • Strong written and verbal communication skills.
  • Bachelor's degree required; BSN preferred.
Qualifications:
  • Active, unrestricted Registered Nurse (RN) license.
  • Medicare Advantage, Medicaid, commercial payer or government payer experience.
  • InterQual, MCG/Care Guidelines, or comparable clinical decision-support experience.
  • Utilization-management accreditation or quality experience.
  • Population health/care management.
  • Behavioral health, post-acute care, specialty care, emergency care, or high-cost/high-risk population experience.
  • VA/VHA experience.
  • CCM, ACM, CPHQ, or similar certification.

Why Tria?
What defines the Tria brand is more than just our dedication to excellence in our craft; it's our incredible team of dedicated, talented, and passionate people that make Tria so exceptional. As people powering possible, we are all partners in our team's shared success.


As a company that cares about people, we seek to cultivate a culture in which all can thrive personallyandprofessionally. We offer a top-tier benefits package to invest in your physical, mental, and financial health and wellness so that you can be your best self - at workand in life. At Tria, we are growth-minded, entrepreneurial in spirit, and committed to fostering a culture of inclusion and opportunity for all. Whatever your background, your role, your department, or stage in your professional journey, here you will have opportunities to learn new skills, seize new challenges, and advance your career as we grow.

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