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Utilization Management Review Nurse Jobs (NOW HIRING)

Fusion HCR

Utilization Review Nurse

Las Vegas, NV · On-site

Direct Hire - Utilization Review Nurse, this is an onsite position, working with our client in ... Collaborate with physicians, case management, and care teams * Support discharge planning and care ...

US Tech Solutions

Utilization Review Nurse

Chicago, IL · On-site

MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge. * MUST HAVE UM experience, inpatient ... Do you have experience with Utilization Review? * Do you have an Active Registered Nurse License?

SPEROS

$77K - $117K/yr

The Utilization Review Nurse serves as a clinical resource in utilization management and denial mitigation within the acute care oncology setting. Job Title: Utilization Review Nurse Minimum ...

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Utilization Management Review Nurse information

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

As of Sep 15, 2026, the average hourly pay for utilization management review nurse 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.

What is a utilization management review nurse?

A Utilization Management Review Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities. They review patient medical records, insurance information, and treatment plans to ensure that provided care meets established guidelines and is medically necessary. These nurses often work for insurance companies, hospitals, or managed care organizations and play a key role in controlling healthcare costs while ensuring patients receive appropriate care.

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

To excel as a Utilization Management Review Nurse, you need a solid background in clinical nursing, active RN licensure, and expertise in utilization review processes. Familiarity with medical necessity criteria (such as InterQual or MCG), electronic medical records, and health insurance systems is commonly required. Strong analytical thinking, attention to detail, and effective communication skills help you collaborate with providers and advocate for appropriate patient care. These skills are crucial for ensuring patients receive necessary and cost-effective treatments while supporting compliance and organizational goals.

How does a utilization management review nurse collaborate with physicians and other healthcare professionals during the review process?

A Utilization Management Review Nurse frequently interacts with physicians, case managers, and other healthcare professionals to ensure that patient care meets established guidelines and is medically necessary. This collaboration often involves reviewing clinical documentation, discussing care plans, and providing feedback to providers about authorization decisions or alternative treatment options. Effective communication and negotiation skills are important, as nurses must sometimes clarify or advocate for appropriate patient care while adhering to payer policies and regulatory standards. Working as part of a multidisciplinary team helps promote optimal patient outcomes and efficient resource use.

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

AspectUtilization Management Review NurseUtilization Review Nurse
CertificationsRN license, possibly certifications like CCM or CUCRN license, often similar certifications
Work EnvironmentManaged care organizations, insurance companies, hospitalsInsurance companies, healthcare providers, managed care
Job FocusReviewing medical necessity for utilization managementAssessing medical necessity and appropriateness of care

Both roles involve reviewing patient cases to ensure appropriate care, often requiring RN licensure and similar certifications. The main difference lies in terminology and specific employer usage, with 'Utilization Management Review Nurse' emphasizing the management aspect, while 'Utilization Review Nurse' is a broader term used across various healthcare settings. Both positions aim to optimize patient care and control costs within healthcare organizations.

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Utilization Management Review Nurse jobs near you
Infographic showing various Utilization Management Review Nurse job openings in the United States as of September 2026, with employment types broken down into 1% As Needed, 83% Full Time, 14% Part Time, and 2% Contract. Highlights an 82% Physical, 2% Hybrid, and 16% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Nurse Home Health Registered Nurse

Houston, TX

Doctor's Choice Home Care & Hospice Texas
See more jobs at Doctor's Choice Home Care & Hospice Texasexternal

Full-time

Posted 11 days ago

Job description

Summary of Essential Functions for the Position:

Committed to Caring, the Utilization Review Nurse (RN) is responsible for reviewing clinical documentation, patient plans of care, and utilization patterns to ensure appropriate, effective, and compliant delivery of home health services. This position focuses on optimizing patient outcomes, managing care utilization, and supporting clinicians in providing the right care at the right time. The Utilization Review Nurse collaborates closely with field clinicians, case managers, and leadership to promote efficiency, quality, and regulatory compliance across all episodes of care.

Qualifications / Licensure / Certification / Knowledge / Skills / Abilities:

  • Current and active RN license in the state of practice required.
  • Minimum 2 years of experience in home health, quality assurance, or utilization management preferred.
  • Knowledge of Medicare Conditions of Participation (CoPs), OASIS documentation, and home health regulatory standards.
  • Experience with EMR systems (Wellsky and WellSky CareInsights or equivalent preferred).
  • Excellent analytical, communication, and critical-thinking skills.
  • Ability to work independently while collaborating effectively with interdisciplinary teams.
  • Knowledge of clinical pathways and evidence-based care guidelines.
  • Strong organizational and time-management abilities.
  • Proficient in data analysis and documentation review.
  • Acceptance and ability to demonstrate support of the core values and goals of Agency.
  • Ability to demonstrate flexibility, initiative, and work with minimal supervision.
  • Strong communication skills, both oral and in writing, with excellent interpersonal skills.

Educational Requirements:

High School Diploma or GED. Graduate of an approved college or university with a at least a diploma or an associate's degree in nursing (ADN) from an accredited nursing program.

Working Conditions & Physical Requirements:

Work environment includes autonomy and can be stressful due to deadlines, multiple tasks and general compliance of law, rules, and regulations. The position requires visual acuity and dexterity, sitting, standing, some pushing, pulling, and lifting up to 25 pounds.

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