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Utilization Review Case Manager Jobs in Kansas (NOW HIRING)

Wesley Medical Center

RN Case Manager

Wichita, KS · On-site

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

Wesley Medical Center

RN Case Manager

Wichita, KS · On-site

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

Wesley Medical Center

RN Case Manager

Wichita, KS

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

Wesley Medical Center

RN Case Manager

Wichita, KS · On-site

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

Wesley Medical Center

RN Case Manager

Wichita, KS · On-site

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

Wesley Medical Center

RN Case Manager

Wichita, KS · On-site

Certification in case management or utilization review is preferred * InterQual experience is preferred Benefits Wesley Medical Center, offers a total rewards package that supports the health, life ...

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All JobsUtilization Review Case JobsUtilization Review Case Manager JobsUtilization Review Case Manager Jobs in Kansas

Utilization Review Case Manager information

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$32

$53

How much do utilization review case manager jobs pay per hour?

As of Sep 6, 2026, the average hourly pay for utilization review case manager in Kansas is $32.54, according to ZipRecruiter salary data. Most workers in this role earn between $26.35 and $34.28 per hour, depending on experience, location, and employer.

What is a utilization review case manager?

A Utilization Review Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical treatments and services provided to patients. They review clinical information, coordinate with providers and insurance companies, and ensure that patient care aligns with established guidelines and policies. Their goal is to optimize patient outcomes while managing healthcare costs and ensuring compliance with regulations.

What are some common challenges utilization review case managers face when coordinating care across multiple departments?

Utilization Review Case Managers often navigate complex communication between physicians, nursing staff, insurance providers, and patients to ensure appropriate care and resource use. Balancing timely authorizations with evolving patient needs and varying documentation standards can be challenging. Additionally, staying current with changing regulations and payer requirements requires ongoing learning and adaptability. Building strong collaborative relationships and maintaining clear, concise documentation are key strategies for overcoming these hurdles.

What are the key skills and qualifications needed to thrive as a utilization review case manager, and why are they important?

To thrive as a Utilization Review Case Manager, you need a clinical background such as an RN or LCSW license, strong knowledge of medical necessity criteria, and experience with case management. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of regulatory guidelines like Medicare and Medicaid are essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration between patients, providers, and payers. These skills ensure appropriate resource use, compliance with regulations, and high-quality patient care.

What is the difference between Utilization Review Case Manager vs Utilization Review Nurse?

AspectUtilization Review Case ManagerUtilization Review Nurse
CredentialsTypically requires a nursing license or relevant healthcare certificationRegistered Nurse (RN) license is required
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinic, insurance review departments
Primary FocusReviewing medical necessity, coordinating care, managing casesAssessing medical records, clinical review, patient care evaluation

Both roles involve healthcare review and require nursing credentials, but the Utilization Review Case Manager often focuses on coordinating care and managing cases, while the Utilization Review Nurse emphasizes clinical assessment and review of medical records. Understanding these differences helps in choosing the right career path or job search focus.

What are popular job titles related to Utilization Review Case Manager jobs in Kansas?

For Utilization Review Case Manager jobs in Kansas, the most frequently searched job titles are:

What job categories do people searching Utilization Review Case Manager jobs in Kansas look for?

The top searched job categories for Utilization Review Case Manager jobs in Kansas are:

Utilization Review Case Manager jobs near you
Infographic showing various Utilization Review Case Manager job openings in Kansas as of August 2026, with employment types broken down into 57% Full Time, and 43% Contract. Highlights an 100% In-person job distribution, with an average salary of $67,683 per year, or $32.5 per hour.

Utilization Review Registered Nurse (UR RN)

ProviDRs Care

Wichita, KS • On-site

Full-time

Posted 9 days ago

Job description


UTILIZATION REVIEW REGISTERED NURSE (UR RN)
Department: Integrated Health Management
Reports To: Integrated Health Management Supervisor/Manager
Clinical Oversight: Medical Director, as applicable
FLSA Status: Non-Exempt
Employment Status: Full-Time, Hourly
Salary: Based on previous work experience and years of experience
POSITION SUMMARY
EMPLOYEE IS REQUIRED TO WORK ON-SITE
The Utilization Review Registered Nurse (UR RN) performs clinical utilization review activities on behalf of health plans administered by the Third-Party Administrator (TPA). The UR RN evaluates requests for healthcare services to determine whether requested services meet established medical-necessity and utilization-management criteria and assists in ensuring services are reviewed in accordance with applicable health plan provisions, organizational policies, and regulatory requirements.
The UR RN performs prospective, concurrent, and retrospective reviews using approved evidence-based clinical criteria, applicable plan documents, clinical policies, and available medical documentation.
The UR RN collaborates with healthcare providers, facilities, the Medical Director, Case Management, Care Navigation, Claims, pharmacy/PBM partners, stop-loss resources, provider networks, and other internal and external stakeholders.
The UR RN may approve services that meet established criteria within delegated authority. Cases that do not meet established criteria or may result in an adverse medical-necessity determination are referred to the Medical Director or other appropriately qualified physician reviewer in accordance with organizational policy and applicable requirements.
ESSENTIAL JOB RESPONSIBILITIES
Utilization Review
  • Perform prospective, concurrent,and retrospective utilization reviews.
  • Review requests for inpatient andoutpatient services, procedures, surgeries, diagnostic testing, therapies,durable medical equipment, specialty medications, and other servicesrequiring utilization review or prior authorization.
  • Review medical records andsupporting clinical documentation to determine whether sufficientinformation is available to complete the review.
  • Apply approved evidence-basedclinical criteria consistently and appropriately.
  • Evaluate diagnoses, treatmentplans, previous treatments, laboratory findings, imaging results,physician documentation, medication history, and other relevant clinicalinformation.
  • Approve services that meetapplicable clinical criteria and fall within delegated nursing authority.
  • Refer cases that do not meetestablished criteria, involve clinical uncertainty, or may result in anadverse medical-necessity determination to the Medical Director or otherqualified physician reviewer.
  • Request additional clinicaldocumentation from providers when necessary.
  • Accurately document the clinicalrationale and criteria used during the review.
  • Complete reviews withinapplicable regulatory, contractual, plan-specific, and departmentalturnaround-time requirements.

Prospective Review / Prior Authorization
  • Review authorization requestssubmitted before services are rendered.
  • Determine whether adequateclinical documentation has been submitted to support the requestedservice.
  • Determine whether requestsqualify for routine or urgent/expedited processing according to applicabledefinitions.
  • Review clinical justificationsubmitted for urgent requests.
  • Apply applicablemedical-necessity criteria and utilization-management requirements.
  • Evaluate requested level of care,site of service, frequency, duration, and other relevant clinical factors.
  • Identify opportunities forclinically appropriate alternative sites of care when applicable.
  • Request missing clinicaldocumentation promptly to avoid unnecessary delays.
  • Refer cases requiringphysician-level clinical judgment to the Medical Director.

Concurrent Review
  • Conduct concurrent review ofinpatient admissions and other ongoing services requiring continuedauthorization.
  • Evaluate continued medicalnecessity and appropriateness of the current level of care.
  • Obtain clinical updates fromhospitals, facilities, and providers.
  • Monitor treatment progression,length of stay, discharge planning, and barriers to discharge.
  • Identify opportunities fortransition to a lower level of care when clinically appropriate.
  • Refer members with complexdischarge needs, significant medical conditions, or ongoingcare-coordination needs to Case Management.
  • Escalate cases involvingpotential reduction or termination of previously authorized servicesaccording to established procedures.
  • Complete continued-stay reviewswithin required timeframes.

Retrospective Review
  • Conduct retrospective reviewswhen services were provided without prospective authorization or whenretrospective review is otherwise appropriate.
  • Evaluate clinical documentationbased on the patient's clinical condition and information available at thetime services were rendered.
  • Apply appropriate clinicalcriteria and plan provisions.
  • Document findings andrecommendations.
  • Refer cases requiringphysician-level determination to the Medical Director.

MEDICAL DIRECTOR & PEER-TO-PEER COORDINATION
  • Identify cases requiring MedicalDirector review.
  • Prepare cases for physicianreview by organizing pertinent clinical information, applicable criteria,previous treatment, relevant plan provisions, and outstanding clinicalquestions.
  • Refer potential medical-necessitydenials, modifications, or other adverse clinical determinations to theappropriate physician reviewer.
  • Coordinate peer-to-peerdiscussions between treating providers and physician reviewers whenappropriate.
  • Document Medical Directordecisions and peer-to-peer outcomes accurately.
  • Process resulting authorizationsor other actions according to the physician's determination and establishedprocedures.
  • Ensure required notifications areinitiated following physician review.
  • Escalate complex or unusualclinical situations to the Supervisor, Manager, Director, and/or MedicalDirector as appropriate.

APPEALS
  • Assist withutilization-management appeals as assigned.
  • Gather medical records, previousdeterminations, clinical criteria, correspondence, and additionalinformation submitted in support of the appeal.
  • Ensure appeals are routed toappropriately qualified reviewers.
  • Maintain awareness of appealturnaround-time requirements and promptly escalate potential delays.
  • Document appeal activities andoutcomes accurately.
  • Process overturned or modifieddeterminations according to established procedures.
  • Assist with member and providernotifications as appropriate.

BENEFIT & PLAN DOCUMENT REVIEW
  • Review applicable Plan Documents,Summary Plan Descriptions, Adoption Agreements, amendments, schedules ofbenefits, exclusions, limitations, and utilization-management provisions.
  • Identify whether requestedservices are subject to prior authorization or otherutilization-management requirements.
  • Recognize the distinction betweena clinical medical-necessity determination and a benefit/coveragedetermination.
  • Identify potential benefitexclusions, limitations, or coverage concerns during clinical review.
  • Escalate unclear, conflicting, orcomplex plan-language questions to the appropriate Supervisor, Manager,Director, Claims, Compliance, or other designated resource.
  • Avoid representing authorizationas a guarantee of coverage or payment.
  • Follow organizationalrequirements regarding appropriate authorization disclaimers andmember/provider communications.

SPECIALTY MEDICATION & PBM COORDINATION
  • Review specialty-medicationrequests when assigned and when the medication is subject toutilization-management review.
  • Identify whether medications aresubject to medical-benefit or pharmacy-benefit requirements.
  • Identify applicablespecialty-medication exclusions, prior authorization requirements,site-of-care requirements, or other plan provisions.
  • Coordinate with PBMs, specialtypharmacies, Case Management, and other appropriate resources.
  • Identify cases that may requireevaluation for alternative funding, manufacturer assistance, PAP/MAPprograms, biosimilars, specialty-pharmacy sourcing, or alternative sitesof care.
  • Escalate complexspecialty-medication coverage or sourcing questions to appropriateleadership.
  • Refer clinical questionsrequiring physician judgment to the Medical Director.

HIGH-COST CLAIM & STOP-LOSS IDENTIFICATION
The UR RN is expected to recognize utilization that may indicate significant health-plan exposure.
Responsibilities include:
  • Identify potentially high-cost orcatastrophic cases during utilization review.
  • Recognize diagnoses, treatments,admissions, specialty medications, transplant cases, neonatal cases,oncology treatment, dialysis, complex surgeries, and other services thatmay warrant additional review or notification.
  • Notify Case Management andappropriate leadership according to established procedures.
  • Assist with obtaining clinicaldocumentation needed for stop-loss reporting when requested.
  • Follow departmental proceduresregarding high-cost claimant identification and stop-loss notification.
  • Maintain appropriate separationbetween financial considerations and clinical medical-necessitydeterminations.

CASE MANAGEMENT & CARE NAVIGATION REFERRALS
Identify and refer members who may benefit from additional support, including members experiencing:
  • Complex or chronic medicalconditions
  • Multiple hospitalizations oremergency department visits
  • High-cost diagnoses or treatments
  • Newly diagnosed seriousconditions
  • Oncology treatment
  • Transplant evaluation ortransplantation
  • Complex medication regimens
  • Significant discharge-planningneeds
  • Difficulty accessing appropriatehealthcare services
  • Potential social determinants ofhealth affecting care
  • Opportunities for provider orsite-of-care navigation

Communicate pertinent information to Case Management and/or Care Navigation to support continuity and coordination of care.
DOCUMENTATION RESPONSIBILITIES
  • Maintain accurate, complete,objective, and timely documentation of utilization-review activities.
  • Document clinical informationreviewed, applicable criteria, communications, requests for additionalinformation, determinations, physician reviews, peer-to-peer discussions,and notifications.
  • Maintain appropriate audit trailswithin the utilization-management system.
  • Document rationale supportingnursing-level approvals and referrals for physician review.
  • Ensure documentation supportsinternal quality reviews, regulatory requirements, employer-planrequirements, stop-loss needs, and audits.
  • Complete documentation duringscheduled working hours unless authorized overtime is required.

COMMUNICATION RESPONSIBILITIES
Communicate professionally and effectively with:
  • Physicians and other healthcareproviders
  • Hospitals and healthcarefacilities
  • Members and authorizedrepresentatives
  • Medical Director and physicianreviewers
  • Case Managers
  • Care Navigators
  • Claims personnel
  • PBMs and specialty pharmacies
  • Provider networks
  • Stop-loss resources
  • Internal leadership
  • Compliance and other internaldepartments

Provide clear information regarding authorization requirements, requested clinical documentation, review status, and next steps while remaining within the scope and authority of the UR RN position.
REGULATORY & COMPLIANCE RESPONSIBILITIES
  • Perform utilization-reviewactivities in accordance with applicable federal and state requirements.
  • Maintain compliance with HIPAAand organizational privacy and confidentiality policies.
  • Follow applicable requirementsfor ERISA and non-ERISA health plans.
  • Follow applicable stateutilization-review requirements.
  • Follow organizational proceduresregarding adverse determinations, appeals, expedited reviews, peer-to-peerreview, and notifications.
  • Maintain appropriate separationbetween clinical medical-necessity review and benefit administration.
  • Participate inutilization-management audits and quality reviews.
  • Complete required compliance,privacy, clinical, and utilization-management education.

QUALITY & PERFORMANCE EXPECTATIONS
Performance may be evaluated based upon:
  • Overall utilization-reviewproductivity
  • Routine and urgent reviewturnaround-time compliance
  • Prospective, concurrent, andretrospective review timeliness
  • Documentation accuracy andcompleteness
  • Appropriate application ofclinical criteria
  • Appropriate escalation to MedicalDirector review
  • Provider communication timeliness
  • Authorization accuracy
  • Quality-audit results
  • Identification ofhigh-risk/high-cost cases
  • Appropriate Case Management andCare Navigation referrals
  • Stop-loss notification compliance
  • Attendance and reliability
  • Compliance with departmentalpolicies and procedures

Performance expectations will not require employees to perform uncompensated work outside recorded working hours.
NON-EXEMPT STATUS, WORK HOURS & TIMEKEEPING
This position is classified as non-exempt under the Fair Labor Standards Act (FLSA) and is eligible for overtime compensation in accordance with applicable federal and state law.
The employee is responsible for accurately recording all hours worked.
The UR RN is expected to:

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