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Utilization Management Nurse Jobs (NOW HIRING)

HJ Staffing

Utilization Management

Long Beach, CA

We are seeking a Registered Nurse (RN) to join our Utilization Management team . In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning ...

New

HJ Staffing

Utilization Management

Long Beach, CA · On-site

We are seeking a Registered Nurse (RN) to join our Utilization Management team . In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning ...

New

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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 24, 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 1% As Needed, 83% Full Time, 13% Part Time, 1% Temporary, and 2% Contract. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $89,483 per year, or $43 per hour.
Utilization Management Nurse II - Case Management

Utilization Management Nurse II - Case Management

CHRISTUS Health

Coushatta, LA • On-site

Full-time

Posted 9 days ago

CHRISTUS Health rating

6.7

Company rating: 6.7 out of 10

Based on 524 frontline employees who took The Breakroom Quiz

532nd of 890 rated healthcare providers

Job description

Summary:
The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.
Responsibilities:
  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i.e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i.e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
  • Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the confidence, drive, and ability to face and overcome challenges and obstacles to achieve organizational goals.
  • Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
  • Excellent verbal and written communication skills, knowledge of clinical protocol, normative data, and health benefit plans, particularly coverage and limitation clauses.
  • Must adjust to frequently changing workloads and frequent interruptions.
  • May be asked to work overtime or take calls.
  • May be asked to travel to other facilities to assist as needed.
  • Actively participates in Multidisciplinary/Patient Care Progression Rounds.
  • Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
  • Documents in the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.

Job Requirements:
Education/Skills
  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience
  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications
  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.

Work Schedule:
5 Days - 8 Hours
Work Type:
Full Time

What CHRISTUS Health employees say

Pay

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Hours and flexibility

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About CHRISTUS Health

Sourced by ZipRecruiter

CHRISTUS Health is a prominent name in the healthcare industry, with its headquarters situated in Irving, TX, USA. Established in 1999, the company has since been devoted to providing comprehensive care and extending the healing ministry of Jesus Christ. This not-for-profit health system primarily operates more than 600 healthcare services and programs, including long-term care facilities, health insurance products, community clinics, and outreach services, serving both urban and rural populations.

Industry

Outpatient health care

Company size

1,001 - 5,000 Employees

Headquarters location

Irving, TX, US

Year founded

1999

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