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Utilization Review Nurse Consultant Jobs (NOW HIRING)

Sentara Health Plans

$65 - $85/hr

The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical ...

Acrisure

Utilization Review Nurse

Bradenton, FL · On-site

Acrisure is seeking a Utilization Review Nurse, LPN to evaluate treatment requests and help ensure injured workers receive appropriate, timely care in accordance with applicable clinical guidelines ...

Acrisure, LLC

Utilization Review Nurse

Bradenton, FL · On-site

$55 - $90/hr

Utilization Review Nurse, LPN** to evaluate treatment requests and help ensure injured workers receive appropriate, timely care in accordance with applicable clinical guidelines and regulatory ...

Acrisure, LLC

$55 - $90/hr

Utilization Review Nurse, LPN** to evaluate treatment requests and help ensure injured workers receive appropriate, timely care in accordance with applicable clinical guidelines and regulatory ...

Acrisure

Utilization Review Nurse

Bradenton, FL

Acrisure is seeking a Utilization Review Nurse, LPN to evaluate treatment requests and help ensure injured workers receive appropriate, timely care in accordance with applicable clinical guidelines ...

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Utilization Review Nurse Consultant information

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How much do utilization review nurse consultant jobs pay per hour?

As of Sep 5, 2026, the average hourly pay for utilization review nurse consultant in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

What are the main challenges a utilization review nurse consultant faces when collaborating with physicians and insurance providers?

Utilization Review Nurse Consultants often encounter challenges when balancing the needs of patients, the expectations of healthcare providers, and the policies of insurance companies. Effective communication is essential, as they must present clinical findings clearly and advocate for appropriate patient care while adhering to insurance guidelines. Navigating disagreements or denials requires strong negotiation skills and a thorough understanding of medical necessity criteria. Building professional relationships and staying current with evolving regulations can help overcome these challenges and improve collaboration.

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

To thrive as a Utilization Review Nurse Consultant, you need a current RN license, strong clinical assessment skills, and knowledge of healthcare regulations and insurance processes. Familiarity with utilization management software, electronic health records (EHRs), and case management systems is typically required, along with certifications like Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ). Exceptional critical thinking, attention to detail, and effective communication are vital soft skills for collaborating with providers and payers. These competencies ensure accurate, ethical, and efficient review of medical services, supporting both patient care quality and cost containment.

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

AspectUtilization Review Nurse ConsultantUtilization Review Nurse
CredentialsRN license, certification in case management or utilization reviewRN license, often with certification in utilization review or case management
Work EnvironmentConsults with healthcare providers, reviews cases for insurance companies or healthcare organizationsPerforms case reviews, often within insurance or hospital settings
Employer & IndustryInsurance companies, healthcare consulting firms, managed care organizationsHospitals, insurance companies, healthcare providers

The Utilization Review Nurse Consultant typically provides expert advice and case management consulting, often working across multiple organizations. In contrast, the Utilization Review Nurse primarily conducts case reviews within specific healthcare or insurance settings. Both roles require RN licensure and certification, but the consultant role emphasizes advisory and strategic functions, while the nurse role focuses on case assessment and approval processes.

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What job categories do people searching Utilization Review Nurse Consultant jobs look for?

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Utilization Review Nurse Consultant jobs near you
Infographic showing various Utilization Review Nurse Consultant job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, and 3% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Nurse

Health Business Solutions LLC

Cooper City, FL • On-site

Full-time

Re-posted 29 days ago

Job description

Job Summary: We are seeking a highly motivated and experienced Utilization Review Nurse to join our team. The Utilization Review Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

·       Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

  • Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
  • Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
  • Utilization Review:

a) Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b) Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c) Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d) Screen cases for Physician Advisor review

e) Collaborate with insurance companies on concurrently denied and high risk for denial cases

  •  Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.


  • Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.


  • Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

·       Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.

·       Bachelor of Science in Nursing (BSN) preferred.

·       Case Management Certification (e.g., CCM) is a plus.

·       Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.

·       Minimum 2 years of work experience in Utilization Review

·       Strong understanding of revenue cycle management and healthcare reimbursement.

·       Proficiency in medical coding and clinical documentation improvement.

·       Excellent communication, interpersonal, and teamwork skills.

·       Ability to work independently and make sound clinical and financial decisions.

·       Strong analytical and problem-solving skills.

·       Proficient in using healthcare information systems and technology.

·       Commitment to maintaining patient confidentiality and ethical standards.