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Utilization Review Director Jobs in California (NOW HIRING)

Prime Healthcare

Utilization Review Nurse LVN

Ontario, CA · On-site

$71K - $99K/yr

Assists Director of UR Dept. in providing oversight and monitoring productivity of UR Coordinators ... Utilization Management experience required. * Excellent interpersonal relationship skills with ...

Kheir Clinic

Utilization Specialist

Los Angeles, CA · On-site

The Utilization Specialist will work closely with the clinical teams, Director of Patient Services ... Review scheduling reports and data analytics to assess current patient flow and identify potential ...

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How much do utilization review director jobs pay per hour?

As of Sep 1, 2026, the average hourly pay for utilization review director in California is $41.73, according to ZipRecruiter salary data. Most workers in this role earn between $32.98 and $47.93 per hour, depending on experience, location, and employer.

What does a utilization review director do?

A Utilization Review Director oversees the evaluation of medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead teams that review patient care requests, manage compliance with regulations, and implement strategies to ensure cost-effective care without compromising quality. Their responsibilities often include policy development, data analysis, and collaboration with healthcare providers to optimize resource use and improve patient outcomes.

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

To thrive as a Utilization Review Director, you need a deep understanding of clinical guidelines, healthcare regulations, and case management principles, typically supported by a nursing or related healthcare degree and relevant licensure. Familiarity with utilization management software, electronic health records (EHR), and certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) is common in the field. Strong leadership, communication, analytical thinking, and decision-making skills help you effectively manage teams and ensure compliance. These competencies ensure efficient resource use, regulatory adherence, and high-quality patient outcomes within healthcare organizations.

What are some common challenges faced by a utilization review director, and how can they be addressed?

A Utilization Review Director often navigates challenges such as balancing regulatory compliance with organizational goals, managing interdisciplinary teams, and keeping up with evolving healthcare policies. Staying proactive with ongoing education, fostering open communication among staff, and implementing efficient review processes can help address these issues. Additionally, leveraging data analytics and technology streamlines case reviews and ensures evidence-based decision-making, ultimately improving both patient outcomes and operational efficiency.

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

AspectUtilization Review DirectorUtilization Review Nurse
CredentialsRN license, management experience, certifications (e.g., CCM)RN license, certification in case management or utilization review (e.g., CUC)
Work EnvironmentAdministrative, leadership roles overseeing teamsClinical, review of patient cases, direct patient care
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentLeadership, management, strategic planning in utilization reviewClinical review, case assessment, patient care coordination

The Utilization Review Director typically oversees review teams and manages utilization strategies, requiring leadership skills and management experience. In contrast, the Utilization Review Nurse focuses on clinical case assessments and patient care reviews. Both roles require RN licensure and relevant certifications but differ mainly in scope and responsibilities.

What are the most commonly searched types of Utilization Review jobs in California?

The most popular types of Utilization Review jobs in California are:

What cities in California are hiring for Utilization Review Director jobs?

Cities in California with the most Utilization Review Director job openings:

Utilization Review Director jobs near you

Director, Utilization Management

Alameda Health System

Oakland, CA • On-site

Full-time

Medical, Retirement, PTO

Re-posted 29 days ago

Alameda Health System rating

8.3

Company rating: 8.3 out of 10

Based on 16 frontline employees who took The Breakroom Quiz

Job description

  • 100% employer health plan for employees and their eligible dependents
  • Unique benefit offerings that are partially or 100% employer-paid
  • Rich and varied retirement plans and the ability to participate in multiple plans.
  • Generous paid time off plans

Role Overview:
Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational oversight, strategic planning, compliance, and collaboration. Their responsibilities span from managing admissions to ensuring clean claims, identifying trends, and optimizing resource utilization. This role supports patient care coordination, fosters physician collaboration, and aligns with organizational objectives while adapting to ad hoc duties as needed. In essence, they orchestrate efficient utilization management to deliver high-quality patient care.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
  • Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations.
  • Monitor and evaluate the utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures.
  • Analyze data and generate reports on utilization trends, outcomes and quality indicators to support decision-making and process improvement initiatives. Reports to appropriate committees.
  • Manage quality of performance criteria, policies and procedures, and service standards for the utilization management operations. Evaluate utilization reviews and determine program improvements.
  • Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements.
  • Direct and coordinate data gathering and record keeping legally required by federal and state agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects
  • Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate the utilization review process.
  • Participate in interdisciplinary committees and meetings to contribute to the development and implementation of quality improvement initiatives.
  • Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payers through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding UM matters.
  • Perform all other duties as assigned.
  • Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
  • Provides in-house educational programs as needed for both staff and physicians.
  • Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of UM and administrative staff.
  • Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.

MINIMUM QUALIFICATIONS:
Required Education: Bachelor's degree in Nursing
Preferred Education: Master's degree in Nursing
Required Experience: Three years of utilization review experience. Health insurance company and/or acute care hospital, post-acute and psych; three years of InterQual and/or MCG. Strong clinical nursing background.
Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.
Preferred Licenses/Certifications: UM / CM certifications

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