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Utilization Review Case Manager Jobs in Dallas, TX

TEKsystems

Utilization Review Specialist

Addison, TX

$70K - $100K/yr

Utilization review experience Additional Skills & Qualifications * Perform utilization review ... Collaborate with physicians, case management teams, and payers to support authorization and ...

TEKsystems

Utilization Review Specialist

Addison, TX

$70K - $100K/yr

Utilization review experience Additional Skills & Qualifications * Perform utilization review ... Collaborate with physicians, case management teams, and payers to support authorization and ...

Oscar Health

Utilization Review Nurse

Dallas, TX · Remote

$35 - $45.94/hr

You will perform frequent case reviews, check medical records and speak with care providers ... Previous experience conducting concurrent or inpatient reviews for a managed care plan This is an ...

Bracane Co

Utilization Review Nurse

Plano, TX · Remote

This position is responsible for performing initial, concurrent review activities; discharge care ... Provides information regarding utilization management requirements and operational procedures to ...

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

As of Aug 23, 2026, the average hourly pay for utilization review case manager in Dallas, TX is $36.09, according to ZipRecruiter salary data. Most workers in this role earn between $29.23 and $38.03 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 Dallas, TX?

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

What job categories do people searching Utilization Review Case Manager jobs in Dallas, TX look for?

The top searched job categories for Utilization Review Case Manager jobs in Dallas, TX are:

What cities near Dallas, TX are hiring for Utilization Review Case Manager jobs?

Cities near Dallas, TX with the most Utilization Review Case Manager job openings:

Utilization Review Case Manager jobs near you
Infographic showing various Utilization Review Case Manager job openings in Dallas, TX as of August 2026, with employment types broken down into 58% Full Time, and 42% Contract. Highlights an 100% In-person job distribution, with an average salary of $75,074 per year, or $36.1 per hour.

RN Utilization Review Coordinator, Full-time

Surgery Partners

Addison, TX • On-site

Full-time

Re-posted 15 days ago

Surgery Partners rating

7.7

Company rating: 7.7 out of 10

Based on 85 frontline employees who took The Breakroom Quiz

160th of 893 rated healthcare providers

Job description

Hiring Now for RN Utilization Review Coordinator
Department: Case Management
Shift: Full-time Hybrid
Job Summary:
The RN Case Manager/Utilization Review is responsible for performing prospective, concurrent, and post-discharge utilization reviews to ensure appropriate patient status, medical necessity, and compliance with hospital policy, payer requirements, and applicable local, state and federal regulations, including Centers for Medicare & Medicaid Services (CMS) guidelines. The role supports accurate admission status determinations, active denial management, and collaboration with physicians, case managers, and interdisciplinary team members to promote efficient patient progression through the episode of care. This position also assists with discharge planning activities and contributes to quarterly and annual utilization review reporting and performance improvement initiatives.
Utilization Review and Medical Necessity
  1. Conduct comprehensive medical record reviews using specific criteria and guidelines as approved and/or established by medical staff, CMS, and other state and federal agencies while ensuring physician and nurse documentation meets set standards.
  2. Perform prospective (pre-admission and pre-operative), concurrent, and post-discharge utilization reviews to verify medical necessity and appropriate level of care throughout the episode of care using the hospital-approved criteria software.
  3. Screen and determine appropriate admission status (inpatient, observation, outpatient, or outpatient in a bed) based on clinical documentation, hospital-approved medical-necessity guidelines, and payer requirements.
  4. Facilitate appropriate admission status determinations based on clinical documentation and payer requirements.
  5. Review clinical documentation for accuracy, completeness, and compliance with regulatory and payer standards.
  6. Collaborate with physicians and nursing staff to ensure timely, accurate orders and documentation supporting medical necessity.
  7. Communicate with physicians when cases do not meet admission or continued stay criteria and assist with resolution.
  8. Submit timely admission, continued stay, and discharge notification and appropriate clinicals to insurance companies as required.
  9. Complete admission status changes as needed in the hospital computer system.

Denial Management:
  1. Identify, track, and manage utilization review denials related to admission status, level of care, length of stay, and medical necessity.
  2. Draft, write, and submit denial appeal letters using clinical judgment, medical record review, applicable payer, CMS, and regulatory guidelines to support medical necessity determinations.
  3. Collaborate with physicians, case managers, physician advisors, and leadership to obtain supporting clinical documentation, physician statements, and peer-to-peer review input for appeals to support denial resolution.
  4. Monitor denial outcomes, appeal success rates, and payer trends; analyze root causes and provide feedback, education, and recommendations to reduce future denials.
  5. Maintain accurate documentation of denials and appeals in accordance with hospital policy and regulatory requirements.

Discharge Planning Support
  1. When needed, collaborate with the Case Management team to support timely and safe discharge planning.
  2. Serve as the patient advocates and enhances collaborative relationships with the healthcare team, physicians, patients, and families to maximize the patient's and family's ability to make informed healthcare decisions.
  3. When needed, assist in identifying and addressing barriers to discharge, including durable medical equipment (DME), home health services, medications, and therapy need.
  4. Reinforce patient and family education to promote successful transitions of care.
  5. When needed, transmit Continuity of Care Documents to appropriate post-acute providers to ensure follow-up care.

Reporting, Compliance & Quality
  1. Monitor, track, and analyze avoidable days and extended lengths of stay; identify contributing factors related to utilization, payer processes, discharge barriers, and system delays, and collaborate with Case Management, physicians, and interdisciplinary teams to support timely resolution.
  2. Assist the Case Management Manager and Quality Director with data collection and analysis for quarterly and annual utilization review reports.
  3. Participate in regulatory audits, surveys, and internal reviews related to utilization management.
  4. Investigate and report adverse occurrences and trends related to utilization, discharge planning, or resource management.
  5. Provide staff education related to utilization review processes, medical necessity, and resource utilization.

Professional Responsibilities:
Must demonstrate high attention to detail, the ability to multi-task, prioritize, and have strong critical thinking skills to address issues that arise unexpectedly.
  1. Must encompass the skill to follow through with tasks and situations while providing clear communication to others throughout the process.
  2. Maintain a high standard of professionalism and ethical conduct in accordance with hospital policies and the Methodist Hospital for Surgery Code of Conduct.
  3. Support and facilitate initiatives enhancing patient outcomes, patient satisfaction, and regulatory compliance.
  4. Communicate effectively, professionally, accurately, and timely with all staff and patients.
  5. Demonstrates the spirit of philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment
  6. Perform other duties as assigned or required.

Minimum Requirements:
Education: Bachelor of Science in Nursing preferred.
Certification, Licensure: Active RN license in Texas; current CPR certification. Case Management Certification(s) preferred.
Experience, Training, Knowledge: At least five years of experience with Case Management, Discharge Planning, and Utilization Review.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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