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Utilization Review Case Manager Jobs (NOW HIRING)

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RN - Case Manager

Honesdale, PA · On-site

$2.50K/wk

Utilization Review / Case Manager RN Location: Honesdale, Pennsylvania 18431 Department: Case Management Pay: $2500/weekly Schedule: * 8-hour Day Shifts * Typical Hours: 7:00 AM - 3:30 PM or 8:00 AM ...

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

As of Jun 1, 2026, the average hourly pay for utilization review case manager in the United States is $36.49, according to ZipRecruiter salary data. Most workers in this role earn between $29.57 and $38.46 per hour, depending on experience, location, and employer.

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 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 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 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.

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Utilization Review Case Manager jobs near you
Infographic showing various Utilization Review Case Manager job openings in the United States as of May 2026, with employment types broken down into 91% Full Time, 7% Part Time, and 2% Contract. Highlights an 94% Physical, 1% Hybrid, and 5% Remote job distribution, with an average salary of $75,891 per year, or $36.5 per hour.

Utilization Review Specialist

ADDICTION AND MENTAL HEALTH SERVICES, LLC

Louisville, TN • On-site

Other

Medical, Dental, Vision, Life, Retirement, PTO

Posted 29 days ago

Job description

About Company:

We’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.

Read more here: https://ow.ly/YQ1C50WuRH1

This certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

Our benefits include:

  • Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

  • Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

  • Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

  • Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

  • Student Loan Repayment – Available for nurses and therapists.

  • Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.

  • Generous PTO – A robust paid time off policy to support work-life balance.

  • Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

At Bradford Health Services, we don’t just invest in our patients—we invest in our people.



About the Role:

The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.

Minimum Qualifications:

  • Bachelor’s degree in Nursing, Health Administration, or a related healthcare field.
  • At least 2 years of experience in utilization review, case management, or clinical healthcare roles.
  • Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
  • Familiarity with insurance authorization processes and healthcare reimbursement models.
  • Excellent analytical, communication, and organizational skills.

Preferred Qualifications:

  • Registered Nurse (RN) license or equivalent clinical certification.
  • Experience with electronic health records (EHR) systems and utilization management software.
  • Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).
  • Prior experience working with managed care organizations or insurance companies.
  • Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.

Responsibilities:

  • Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.
  • Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.
  • Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.
  • Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.
  • Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.

Skills:

The Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.

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