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Utilization Review Np Jobs in Michigan (NOW HIRING)

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... LMSW, LPC, RN or LVN licensure in the state of Michigan required. 3-5 years direct clinical ...

UHS

Manager of Utilization Review

Saint Johns, MI

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... LMSW, LPC, RN or LVN licensure in the state of Michigan required. 3-5 years direct clinical ...

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... LMSW, LPC, RN or LVN licensure in the state of Michigan required. 3-5 years direct clinical ...

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... LMSW, LPC, RN or LVN licensure in the state of Michigan required. 3-5 years direct clinical ...

UHS

Manager of Utilization Review

Saint Johns, MI · On-site

Cedar Creek Hospital Description The Manager of Utilization Review is responsible for managing and ... LMSW, LPC, RN or LVN licensure in the state of Michigan required. 3-5 years direct clinical ...

Trinity Health

NP/PA Surgery - Urology

Ann Arbor, MI · On-site

$106K - $137K/yr

... utilization review processes. In partnership with the supervising physician, the NP/PA evaluates care based on quality and core measures, access, and cost effectiveness. The NP/PA contributes to ...

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Utilization Review Np information

What does a utilization review nurse practitioner do?

A Utilization Review Nurse Practitioner (NP) evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance coverage to ensure that care meets established guidelines and regulatory requirements. Utilization Review NPs help coordinate care, prevent unnecessary procedures, and support cost-effective healthcare delivery while ensuring patient safety and quality outcomes.

What are some common challenges utilization review nurse practitioners face when collaborating with healthcare providers and insurance companies?

Utilization Review Nurse Practitioners often navigate the challenge of balancing patient advocacy with payer requirements. They must effectively communicate clinical justifications to both healthcare providers and insurance representatives, sometimes mediating disagreements over the necessity of certain treatments or hospital stays. Staying up-to-date with ever-changing insurance guidelines and ensuring timely documentation can also be demanding, but strong organizational and interpersonal skills help facilitate smooth collaboration and successful patient outcomes.

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

To thrive as a Utilization Review Nurse Practitioner (NP), you need expert clinical judgment, a strong understanding of healthcare regulations, and advanced assessment skills, typically supported by an active NP license and clinical experience. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines such as Medicare and Medicaid are commonly required. Excellent communication, attention to detail, and critical thinking are vital soft skills for effective case evaluations and collaboration with providers. These competencies ensure accurate, efficient reviews that support quality care, compliance, and cost-effective treatment decisions.

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

AspectUtilization Review NpUtilization Review Nurse
CredentialsMaster's degree in Nursing, Nurse Practitioner certification, state licensureRegistered Nurse (RN) license, possibly with certification in utilization review
Work EnvironmentHealthcare facilities, insurance companies, utilization review organizationsHospitals, insurance companies, outpatient clinics
Job ResponsibilitiesAssess medical necessity, authorize treatments, make clinical decisions, often with greater autonomyReview medical records, support authorization processes, follow established guidelines

Utilization Review NPs typically have advanced clinical training and greater decision-making authority compared to Utilization Review Nurses. Both roles focus on evaluating medical necessity, but NPs often perform more complex assessments and can make independent recommendations, whereas nurses support the review process under supervision or guidelines.

What are popular job titles related to Utilization Review Np jobs in Michigan?

For Utilization Review Np jobs in Michigan, the most frequently searched job titles are:

What job categories do people searching Utilization Review Np jobs in Michigan look for?

The top searched job categories for Utilization Review Np jobs in Michigan are:

What cities in Michigan are hiring for Utilization Review Np jobs?

Cities in Michigan with the most Utilization Review Np job openings:

Utilization Review Np jobs near you
Infographic showing various Utilization Review Np job openings in Michigan as of August 2026, with employment types broken down into 80% Full Time, and 20% Contract. Highlights an 80% In-person, and 20% Remote job distribution.

Utilization Review Specialist Registered Nurse - Behavioral Health

McLaren

Bay City, MI • On-site

Per diem

Posted 11 days ago

Job description

Department: Behavioral Health
Daily Work Times: 7:00am - 3:00pm
Shift: Variable
Hours Per Pay Period: 0
Position Summary:
In conjunction with the admitting/attending physician, the UR Specialist RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews as directed in the hospital's UR Plan of medical records to ensure criteria for admission and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.
Job Specific Duties and Responsibilities:
  1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
  2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
  3. Works collaboratively with case management to expedite patient discharge.
  4. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
  5. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
  6. Identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
  7. Analyzes, updates, and modifies procedures and processes to continually improve utilization review operations.
  8. Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
  9. Complies with federal, state, and local legal and certification requirements by studying existing and new legislation; anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
  10. Performs other related duties as required and directed.

Required
  • Nursing degree from an accredited educational institution
  • State of Michigan licensure as a Registered Nurse (RN)
  • Two years of recent clinical or utilization management experience

Preferred:
  • Bachelor's degree in nursing.
  • Three years of recent case management or utilization management experience
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About McLaren

Sourced by ZipRecruiter

McLaren Group is globally renowned as one of the world’s most illustrious high-technology brands. Since the formation of McLaren Racing in 1963, McLaren has been pioneering and innovating in the competitive world of Formula 1, forging a formidable reputation which has seen the racing team win 20 World Championships and over 180 races. The Group has built on its successful racing expertise and diversified to include a global, high-performance sports car business, McLaren Automotive, and a game-changing technology and innovation business, McLaren Applied. Despite the broadening of the group’s business interests, McLaren’s goal remains singular: we exist to win in everything we do.

Industry

Automobile dealers and manufacturing

Company size

10,000+ Employees

Headquarters location

Woking, Surrey, GB

Social media

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