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Utilization Management Nurse Jobs in Decatur, GA

Elevance Health

Nurse Reviewer 1

Atlanta, GA · On-site

Nurse Reviewer 1 Nurse Reviewer 1 Location: This role enables associates to work virtually ... Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health ...

Elevance Health

Nurse Reviewer 1

Atlanta, GA

Nurse Reviewer 1 Location: This role enables associates to work virtually full-time, with the ... Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health ...

genex

Telephonic Nurse Case Manager

Atlanta, GA · On-site

Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...

genex

Telephonic Nurse Case Manager

Atlanta, GA

Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...

Genex

Telephonic Nurse Case Manager

Atlanta, GA · On-site

Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Main responsibilities include but are not limited to: • Uses clinical/nursing skills to determine ...

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All JobsUtilization Management Nurse JobsUtilization Management Nurse Jobs in Decatur, GA

Utilization Management Nurse information

See Decatur, GA salary details

$38.1K

$87.4K

$159.1K

How much do utilization management nurse jobs pay per year?

As of Jul 23, 2026, the average yearly pay for utilization management nurse in Decatur, GA is $87,365.00, according to ZipRecruiter salary data. Most workers in this role earn between $63,000.00 and $102,000.00 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.
More about Utilization Management Nurse jobs
What are the most commonly searched types of Utilization Management Nurse jobs in Decatur, GA? The most popular types of Utilization Management Nurse jobs in Decatur, GA are:
What are popular job titles related to Utilization Management Nurse jobs in Decatur, GA? For Utilization Management Nurse jobs in Decatur, GA, the most frequently searched job titles are:
What job categories do people searching Utilization Management Nurse jobs in Decatur, GA look for? The top searched job categories for Utilization Management Nurse jobs in Decatur, GA are:
What cities near Decatur, GA are hiring for Utilization Management Nurse jobs? Cities near Decatur, GA with the most Utilization Management Nurse job openings:
Utilization Management Nurse jobs near you
Infographic showing various Utilization Management Nurse job openings in Decatur, GA as of July 2026, with employment types broken down into 1% As Needed, 82% Full Time, 13% Part Time, 1% Temporary, and 3% Contract. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $87,365 per year, or $42 per hour.
Patient Care Coordinator RN

Patient Care Coordinator RN

Kaiser Permanente

Atlanta, GA • On-site

$44.14/hr

Other

Posted 14 days ago

Job description

Job Summary:

Responsible for optimizing quality and efficiency of care for hospitalized members by conducting daily utilization and quality reviews, discharge planning, and care coordination. Collaborates with physicians and multidisciplinary teams, developing safe discharge plans, and ensuring compliance with all relevant regulations. The role promotes high customer satisfaction and achieves desired utilization and quality outcomes for the population served.

Essential Responsibilities:

  • Utilizes established criteria, to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission.
  • Performs an admission utilization review upon admission.
  • Assesses discharge planning needs and documents assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begins the discharge planning process immediately.
  • Conducts a concurrent utilization review of all patients daily and as appropriate based on criteria and policy.
  • Assess daily all patients for post-hospital care planning and coordinate discharge plans, ensuring appropriate level of care in the most suitable setting.
  • Performs daily bedside rounds on patients and/or significant other to update on discharge planning.
  • Reviews charts daily to ensure progression of plan of care and to prepare for daily discharge planning needs.
  • Escalate barriers to discharge in real time after usual processes cannot affect discharge.
  • Leverages written escalation pathways to ensure timely care and timely discharge for patients.
  • Establishes and evolves a discharge plan in parallel with the medical plan to ensure patients discharge plan is ready at the same time as medical clearance.
  • Perform and documents a social screening assessment for all patients admitted to hospital and places referrals to internal programs and social workers as appropriate.
  • Prepares for and attends all scheduled rounds with physician partners and leaders to discuss clinical courses, discharge planning, barriers to care / discharge and quality concerns.
  • Communicate regularly with hospitalist partners and other healthcare team members to monitor patient progress and address delays or quality issues.
  • Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed and planning for discharge along the hospital stay.
  • Arranges follow up appointments for medical and surgical patients who are discharged home as needed.
  • Ensure that the appropriate level of care is being delivered in the most appropriate setting.
  • Performs quality of care and service reviews using identified quality indicators.
  • Performs readmission reviews and identifies plan of care for discharge to prevent future readmissions.
  • Send appropriate referrals for post-acute needs.
  • Secure post-acute services for discharging patients in advance of medical clearance.
  • Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
  • Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care.
  • Builds effective working relationships with physicians, department staff, post-acute staff, vendors, and other departments within the health plan.
  • Assists in the development and revision of guidelines, pathways and protocols.
  • Coordinate case conferences for complex cases and facilitate transfers to appropriate facilities.
  • Documents a daily progress note in EMR with evolving discharge plan
  • Refers cases identified as risk or quality issues to the appropriate department for review using the appropriate reporting tool.
  • Document Review Activities to include (according to policy): Medical necessity for admission. Medical necessity for continued stay. Estimated length of stay. Diagnoses. Procedures performed. Demographic Data. Discharge Planning. Physicians are involved in care.
  • Issue letters of non-coverage to members not meeting inpatient level of care criteria per established criteria and policy and procedure.
  • Works cross-functionally with other departments in striving to meet organizational goals and objectives.
  • Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management.
  • Knowledgeable and compliant with regional personnel policies and procedures.
  • Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
  • Participates in annual regional and departmental compliance training.
  • Knowledgeable and compliant with Principles of Responsibility.
  • Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and license requirements (if applicable), and Kaiser Permanentes policies and procedures.
  • Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues.
  • Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.
  • Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI).
  • Demonstrates doing the right thing and doing things the right way is an underlying premise in all work-related activities and can identify location of copy of Principles of Responsibility.
  • Develops and maintains an awareness of how to report compliance issues and concerns. Escalates compliance issues to immediate or appropriate supervisors.
  • Refers to physician advisor when there is disagreement on patient class, level of care, continued stay or discharge.
  • Other duties as assigned.

Basic Qualifications:
Experience

  • Minimum two (2) years of RN experience in utilization/case management, discharge planning, quality improvement, or patient care delivery in a healthcare setting.
Education

  • Bachelors Degree in Nursing or four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
License, Certification, Registration
  • Registered Professional Nurse License (Georgia)

Additional Requirements:
  • Working knowledge of all relevant federal, state, local and regulatory requirements.
  • Functional knowledge of computers and experience with managed health care delivery, including Medicare.
  • Advanced communication and interpersonal skills with all levels of internal and external customers.
  • Ability to collaborate effectively with multidisciplinary healthcare teams.
  • Excellent time management skills; ability to work in a fast-paced environment.
  • Experience in a health plan environment is highly desirable.
Preferred Qualifications:

  • Minimum three (3) years of clinical nursing experience, preferably in complex or acute care settings preferred.
  • Minimum two (2) years of experience in utilization review, case management, and discharge planning preferred.
  • Complex Case Management Certification (CCM) preferred.
  • Knowledge of funding, resources, services, and outcomes preferred.
  • Masters degree in nursing, Health Care, or Case Management preferred.

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