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Utilization Management Review Nurse Jobs (NOW HIRING)

Umpqua Health

Utilization Review Nurse

Roseburg, OR · On-site +1

$85K - $105K/yr

POSITION PURPOSE The Utilization Management Nurse evaluates clinical service requests to ensure ... review or case management experience in managed care * Oregon residency and license * Bilingual or ...

Umpqua Health

Utilization Review Nurse

$85K - $105K/yr

Position Purpose The Utilization Management Nurse evaluates clinical service requests to ensure ... review or case management experience in managed care * Oregon residency and license * Bilingual or ...

Umpqua Health

Utilization Review Nurse

$85K - $105K/yr

POSITION PURPOSE The Utilization Management Nurse evaluates clinical service requests to ensure ... review or case management experience in managed care * Oregon residency and license * Bilingual or ...

AbsoluteCARE

Utilization Review Nurse

New Orleans, LA · On-site

We use population health management tools to employ a holistic approach to caring for the highest ... The Utilization Review Nurse ensures appropriate utilization of health services by performing ...

Umpqua Health

Utilization Review Nurse

Roseburg, OR · Remote

$85K - $105K/yr

POSITION PURPOSE The Utilization Management Nurse evaluates clinical service requests to ensure ... review or case management experience in managed care * Oregon residency and license * Bilingual or ...

AbsoluteCare

Utilization Review Nurse

New Orleans, LA · On-site

We use population health management tools to employ a holistic approach to caring for the highest ... The Utilization Review Nurse ensures appropriate utilization of health services by performing ...

Bracane Co

Utilization Review Nurse

Plano, TX · Remote

Provides information regarding utilization management requirements and operational procedures to ... Registered Nurse (RN) with a valid, current, unrestricted license in the state of operations. * 3 ...

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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 Aug 10, 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 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.

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 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.

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.
More about Utilization Management Review Nurse jobs
What cities are hiring for Utilization Management Review Nurse jobs? Cities with the most Utilization Management Review Nurse job openings:
What job categories do people searching Utilization Management Review Nurse jobs look for? The top searched job categories for Utilization Management Review Nurse jobs are:
Utilization Management Review Nurse jobs near you
Infographic showing various Utilization Management Review Nurse job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, and 3% Contract. Highlights an 92% Physical, 3% Hybrid, and 5% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Nurse- Care Coordination Department

Northwell Health

Poughkeepsie, NY • On-site

$48.49 - $73.58/hr

Full-time

Re-posted 6 days ago

Northwell Health rating

7.8

Company rating: 7.8 out of 10

Based on 563 frontline employees who took The Breakroom Quiz

131st of 887 rated healthcare providers

Job description

Description
Northwell is the largest not-for-profit health system in the Northeast, serving residents of New York and Connecticut with 28 hospitals, more than 1,000 outpatient facilities, 22,000 nurses and over 20,000 physicians. Northwell cares for more than three million people annually in the New York metro area, including Long Island, the Hudson Valley, Connecticut and beyond, thanks to philanthropic support from our communities. Northwell is New York State's largest private employer with over 104,000 employees - including members of Northwell Health Physician Partners - who are working to change health care for the better.
Summary:
The Utilization Review Nurse is responsible for conducting timely, accurate, and comprehensive clinical reviews to ensure that patients receive the appropriate level of care in accordance with regulatory, payer and organizational guidelines. The Utilization Review Nurse applies evidence-based criteria to evaluate medical necessity and collaborates with physicians and interdisciplinary team members to reduce denials and ensure compliance with CMS and payer regulations.
Responsibilities:
1. Clinical Review & Level of Care Determination
  • Performs initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
  • Applies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
  • Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
  • Ensures MOON, IMN, HINN (etc.) notices are issued and documented per policy.

2. Payer Communication & Authorization Management
  • Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
  • Provides clinical updates and facilitates peer-to-peer reviews as required.
  • Maintains documentation of all payer interactions in Cerner.
  • Securely maintains all relevant login credentials for all payer portals.
  • Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.

3. Collaboration with Clinical Team
  • Discusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria, sends it to the Physician Advisor for a second-level review.
  • Forwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
  • Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
  • Coordinates with the care team to change patient status as needed.
  • Notifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.

4. Compliance & Performance Standards
  • Adheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
  • Maintains confidentiality of patient information in accordance with HIPAA.
  • Meets productivity standards, including review volume, timeliness, and documentation quality.

5. Hybrid Work Standards and Accountability
  • Adheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.

Maintains and models organization values.
Demonstrates regular, reliable and predictable attendance.
Performs other duties as required.
Education Skills Experience:
Associate's degree in nursing
3 years experience in acute care or subacute care Nursing
3 years experience as Utilization Management Nurse in an acute care or subacute care setting preferred.
PREFERRED: Bachelor's degree or master's degree in nursing Current NYS RN License.
CCM/ACM Preferred
NYS PRI certification preferred; required within 60 days of hire. MCG Certification Preferred
Working Conditions
Derived Working Conditions
Essential:
* Significant manual skills / motor coord & finger dexterity
* Significant occupational risk
* Very Heavy effort. May exert up to 50 lbs. force
* Significant exposure to dirt, odor, noise, human waste, etc.
Company: Vassar Brothers Medical Center
Org Unit: 1190
Department: Care Coordination
Exempt: No
Hourly Rate: $48.49-$73.58

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