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Utilization Review Case Manager Jobs in Houston, TX

Nexus Health Systems

RN Case Manager

Shenandoah, TX · On-site

Practices "minimum information necessary" when performing utilization review, case management, and discharge functions. * Acts as a patient advocate for all patients within the facility. * Adheres to ...

Actalent

Utilization Review Nurse

Houston, TX · On-site

$30 - $40/hr

Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria ... Knowledge of utilization management processes. Work Environment The role involves collaboration ...

Actalent

Concurrent Review Nurse

Houston, TX · On-site

... case management, and other support services as appropriate. * Educate providers on utilization ... Review members' transfer and discharge plans to promote continuity of care and minimize gaps ...

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All JobsUtilization Review Case JobsUtilization Review Case Manager JobsUtilization Review Case Manager Jobs in Houston, TX

Utilization Review Case Manager information

See Houston, TX salary details

$15

$34

$57

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

As of Aug 30, 2026, the average hourly pay for utilization review case manager in Houston, TX is $34.84, according to ZipRecruiter salary data. Most workers in this role earn between $28.22 and $36.73 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 Houston, TX?

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

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

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

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

Cities near Houston, 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 Houston, TX as of August 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution, with an average salary of $72,474 per year, or $34.8 per hour.

Remote UTILIZATION REVIEW NURSE - RN

Nexus Health Systems

Houston, TX • On-site

Other

Medical, Dental, Vision, Retirement, PTO

Posted 22 days ago

Nexus Health Systems rating

6.3

Company rating: 6.3 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Job description

Remote Utilization Review Registered Nurse (UR RN)

Nexus Health Systems is seeking an experienced Utilization Review Registered Nurse (UR RN) to join our growing Utilization Management team. This fully remote position plays a critical role in ensuring patients receive medically necessary, high-quality care while promoting appropriate resource utilization and regulatory compliance.

If you're a detail-oriented RN with experience in utilization review, case management, or behavioral health and enjoy collaborating with interdisciplinary teams to improve patient outcomes, we'd love to hear from you.

What You'll Do
  • Conduct concurrent and retrospective utilization reviews to determine medical necessity and appropriate level of care.
  • Apply evidence-based criteria, including InterQual (or similar), to support clinical decision-making and payer compliance.
  • Collaborate with physicians, case managers, and interdisciplinary teams to facilitate timely authorizations, discharge planning, and appropriate transitions of care.
  • Review clinical documentation to ensure accuracy, completeness, and compliance with payer and regulatory requirements.
  • Manage insurance authorizations, denials, appeals, and level-of-care determinations.
  • Monitor utilization trends and contribute to quality improvement initiatives that enhance patient outcomes and operational efficiency.
  • Participate in multidisciplinary utilization review meetings and provide recommendations to optimize care delivery.
  • Maintain accurate documentation within the electronic health record (EHR) while ensuring HIPAA compliance.
Qualifications

Required

  • Associate Degree in Nursing (ADN) from an accredited nursing program.
  • Current, unrestricted Texas RN license or Compact RN license.
  • Minimum of 2 years of acute care clinical nursing experience.
  • At least 3 years of Utilization Review or Case Management experience involving complex medical/surgical and/or behavioral health patients.
  • Strong knowledge of payer guidelines, medical necessity criteria, and utilization management principles.
  • Excellent critical thinking, communication, and organizational skills.
  • Proficiency with electronic health records (EHRs) and Microsoft Office applications.

Preferred

  • Bachelor of Science in Nursing (BSN).
  • Experience with InterQual or MCG criteria.
  • Behavioral health utilization review experience.
  • Experience with Meditech.
  • Professional certifications such as CCM, CPHQ, or HCQM.
Why Nexus Health Systems?

At Nexus Health Systems, our mission is to improve lives through compassionate, high-quality care. As a member of our Utilization Review team, you'll collaborate with dedicated healthcare professionals while helping ensure patients receive the right care at the right time.

We offer:

  • Competitive compensation
  • Comprehensive medical, dental, and vision benefits
  • Paid time off and company holidays
  • 401(k) with company match
  • Professional development and continuing education opportunities
  • A collaborative, mission-driven culture
  • Fully remote work environment

If you're ready to make a meaningful impact in healthcare while enjoying the flexibility of working remotely, we'd love to hear from you.

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