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Utilization Nurse Reviewer Jobs (NOW HIRING)

Dane Street

PRN Utilization Review Nurse Reviewer

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment ...

Elevance Health

Nurse Reviewer I

$35.54 - $55.73/hr

Nurse Reviewer I Nurse Reviewer I Seeking RNs that have a current, unrestricted RN license in ... Previous utilization and/or quality management and/or call center experience preferred. For ...

Elevance Health

Nurse Reviewer I

Chicago, IL · On-site

$35.54 - $55.73/hr

Nurse Reviewer I Nurse Reviewer I *Seeking RNs that have a current, unrestricted RN license in ... Previous utilization and/or quality management and/or call center experience preferred. For ...

Elevance Health

Nurse Reviewer I

Los Angeles, CA · On-site

$35.54 - $55.73/hr

Nurse Reviewer I Nurse Reviewer I *Seeking RNs that have a current, unrestricted RN license in ... Previous utilization and/or quality management and/or call center experience preferred. For ...

Penn Medicine

Utilization Review Nurse

West Chester, PA · On-site

The Utilization Review Nurse will provide utilization review for authorization, concurrent review and discharge review services using InterQual criteria guidelines to validate medical necessity and ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

Elevance Health

Nurse Reviewer I

Los Angeles, CA · On-site

$35.54 - $55.73/hr

Nurse Reviewer I Nurse Reviewer I *Seeking RNs that have a current, unrestricted RN license in ... Previous utilization and/or quality management and/or call center experience preferred. For ...

Elevance Health

Nurse Reviewer I

Chicago, IL · On-site

$35.54 - $55.73/hr

Nurse Reviewer I * Seeking RNs that have a current, unrestricted RN license in either the state of ... Previous utilization and/or quality management and/or call center experience preferred. For ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical ...

Astiva Health, Inc

UM Nurse Reviewer

Orange, CA · On-site

Utilization Management Authorization Review Nurse Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering ...

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Utilization Nurse Reviewer information

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How much do utilization nurse reviewer jobs pay per hour?

As of Sep 9, 2026, the average hourly pay for utilization nurse reviewer 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 nurse reviewer?

Utilization Nurse Reviewers are registered nurses who assess the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance information to ensure that care meets established guidelines and is covered by insurance policies. Their work helps prevent unnecessary treatments and controls healthcare costs, while ensuring patients receive proper care. Utilization Nurse Reviewers often work for hospitals, insurance companies, or healthcare organizations.

What skills and qualifications are needed to be a utilization nurse reviewer?

To thrive as a Utilization Nurse Reviewer, you need a registered nursing license, strong clinical knowledge, and experience in case management or utilization review. Familiarity with healthcare utilization management software, electronic medical records (EMRs), and knowledge of regulatory standards like Medicare and Medicaid guidelines are typically required. Excellent analytical, communication, and decision-making skills help in evaluating medical necessity and collaborating with healthcare providers. These skills ensure accurate, efficient review processes and compliance with regulations, ultimately supporting quality patient care and cost-effective resource use.

How does a utilization nurse reviewer collaborate with physicians and other healthcare professionals?

Utilization Nurse Reviewers work closely with physicians, case managers, and other healthcare team members to ensure that patient care meets established guidelines and payer requirements. They often communicate directly with providers to clarify clinical information, discuss treatment plans, and advocate for medically necessary services. This collaborative approach helps facilitate timely approvals, reduces denials, and promotes quality patient outcomes. Strong interpersonal and communication skills are essential for building effective working relationships and ensuring a smooth review process.

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

AspectUtilization Nurse ReviewerUtilization Review Nurse
CertificationsRN license, possibly certifications in case management or utilization reviewRN license, certifications in case management or utilization review often preferred
Work EnvironmentHospitals, insurance companies, healthcare facilitiesInsurance companies, healthcare organizations, managed care settings
Job FocusReview medical records to determine necessity of services, ensure appropriate careAssess medical necessity, authorize or deny services based on criteria

While both roles involve reviewing medical records and determining the necessity of healthcare services, the Utilization Nurse Reviewer often focuses on detailed case reviews within healthcare facilities, whereas the Utilization Review Nurse typically works in insurance or managed care settings, making decisions on service authorization and coverage.

How much do utilization nurse reviewers make in the US?

Utilization nurse reviewers in the US typically earn between $70,000 and $90,000 annually, depending on experience, location, and employer. They review medical records and determine appropriate healthcare utilization, often working in healthcare or insurance settings with knowledge of clinical guidelines and coding systems.

How to get into utilization review as a utilization nurse reviewer?

To become a utilization nurse reviewer, candidates typically need a registered nurse (RN) license and experience in clinical or case management roles. Certification in utilization review, such as the Certified Professional in Healthcare Quality (CPHQ), can enhance prospects, and familiarity with medical records, insurance policies, and healthcare regulations is essential.

What cities are hiring for Utilization Nurse Reviewer jobs?

Cities with the most Utilization Nurse Reviewer job openings:

What states have the most Utilization Nurse Reviewer jobs?

States with the most job openings for Utilization Nurse Reviewer jobs include:

What are popular job titles related to Utilization Nurse Reviewer jobs?

For Utilization Nurse Reviewer jobs, the most frequently searched job titles are:

Utilization Nurse Reviewer jobs near you
Infographic showing various Utilization Nurse Reviewer job openings in the United States as of August 2026, with employment types broken down into 3% As Needed, 56% Full Time, 14% Part Time, and 27% Contract. Highlights an 99% Physical, and 1% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

PRN Utilization Review Nurse Reviewer

Remote

Dane Street, LLC
Insurance Actuarial and Claim Adjusting Services • 51 - 200 employees
Learn more about Dane Street, LLCexternal

Full-time, Per diem

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 12 days ago

Job description

The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments.
Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways.
Our PRN Nursing Program is designed for flexible, as-needed staffing to support our team during peak times, weekends, and holidays.
  • PRN nurses will be required to work at least one weekend per month, one major holiday, and one minor holiday per year.
  • A minimum number of shifts per month will be mandated to ensure that PRN nurses maintain their QA skills and familiarity with processes.

MAJOR DUTIES & RESPONSIBILITIES
  • Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria).
  • Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services.
  • Offer clinical expertise and serve as a clinical reference for non-clinical staff members.
  • Input and manage essential clinical details within various medical management platforms.
  • Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review.
  • Apply clinical reasoning to determine the suitable evidence-based guidelines.
  • Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director.

Requirements
  • Proficient in both written and spoken communication.
  • Capable of maintaining professional communication with physicians and clients.
  • Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting.
  • Possesses a keen organizational sense and pays close attention to details.
  • Adept at resolving intricate and multifaceted problems.
  • Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook.
  • Background in medical or clinical practice through education, training, or professional engagement.
  • Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs).

Additional Duties
  • May provide oversight to the work of the team members.
  • Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction.
  • Responsible for the final approval on cases for release to the client.
  • Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations.

EDUCATION/CREDENTIALS:
Licensed Practical/Vocational Nurse with an active and unrestricted license to practice.
JOB RELEVANT EXPERIENCE:
2 yrs minimum clinical nursing experience is required.
One year of previous experience in Utilization Management is required.
JOB RELATED SKILLS/COMPETENCIES:
Demonstrate strong abilities in both spoken and written communication, along with effective interpersonal skills. Possess a proficient understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Show the capability to acquire new skills and competencies to address the evolving requirements of systems, software, and hardware.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.
WORK FROM HOME TECHNICAL REQUIREMENTS:
Supply and support their own internet services.
Maintaining an uninterrupted internet connection is a requirement of all work from home position.
Requirements
Beginning compensation will depend on several factors including the candidate's experience, education, and specific skills. In addition to the base salary, we offer a comprehensive benefits package including health insurance, retirement plans, and performance bonuses.
Our Commitment:
We are committed to providing fair and competitive compensation that reflects each employee's contributions and performance. We value diversity and strive to create an inclusive environment for all employees.
Benefits
Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.
ABOUT DANE STREET:
A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

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