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Utilization Review Nurse Jobs in Decatur, GA (NOW HIRING)

Utilization Review Specialist

Atlanta, GA · Remote

$47.40 - $54.95/hr

The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR ...

The nurse will be responsible for reviewing claims that pend to Medical Review to ensure all ... Ability to identify areas to improve cost, quality, and utilization of care within a population

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...

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Utilization Review Nurse information

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$41

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How much do utilization review nurse jobs pay per hour?

As of Jun 21, 2026, the average hourly pay for utilization review nurse in Decatur, GA is $41.28, according to ZipRecruiter salary data. Most workers in this role earn between $32.64 and $47.40 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Utilization Review Nurse, and why are they important?

To thrive as a Utilization Review Nurse, you need a strong background in clinical nursing, critical thinking, and knowledge of healthcare regulations, usually supported by an RN license and nursing degree. Familiarity with utilization management software, medical coding systems (like ICD-10 and CPT), and case management certifications (such as CCM or URAC) is typically required. Excellent communication, negotiation, and organizational skills help you collaborate with providers and advocate for patient care while managing complex cases. These skills ensure appropriate resource use, regulatory compliance, and high-quality patient outcomes in healthcare settings.

What does a Utilization Review Nurse do?

A Utilization Review Nurse is responsible for evaluating the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, coordinate with healthcare providers, and ensure that care meets established guidelines and insurance requirements. Their primary goal is to ensure patients receive appropriate care while helping to manage healthcare costs and prevent unnecessary procedures.

What are some typical challenges Utilization Review Nurses face when communicating with healthcare providers and insurance companies?

Utilization Review Nurses often need to balance clinical judgment with insurance guidelines, which can lead to challenging conversations with providers who may disagree with coverage decisions. They must clearly explain the rationale behind approvals or denials and ensure all documentation is thorough and compliant. Navigating differing priorities while maintaining positive, professional relationships is key, and strong communication skills help facilitate collaboration and resolve conflicts efficiently.

What Does a Utilization Review Nurse Do?

A utilization review nurse determines the best course of treatment for a patient using preapproved policy criteria. Utilization review nurses collect and review patient records, clinical documentation, and billing information to recommend the best use of patient care resources. Their assessments help determine the length of hospital stays, the effectiveness of the care plan, and the necessity of the services administered. Utilization review nurses inform and educate patients about their options based on their insurance benefits and limitations. Utilization review nurses also assess patient care services in clinical appeals for approval or denial.

How to make $150,000 as a nurse?

To earn $150,000 as a Utilization Review Nurse, gaining extensive experience, obtaining certifications such as the Certified Professional Utilization Review (CPUR), and working in high-demand settings like insurance companies or managed care organizations can help increase earning potential. Advanced skills in medical record review, strong knowledge of healthcare policies, and sometimes working overtime or in leadership roles contribute to higher salaries.

What does a nurse do in a utilization review?

A utilization review nurse evaluates medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They ensure that patient care aligns with insurance policies and clinical guidelines, often working with healthcare providers and insurance companies to approve or deny services. This role requires strong clinical knowledge, attention to detail, and familiarity with healthcare regulations and documentation tools.

How to get into utilization review as a nurse?

To become a utilization review nurse, you typically need to be a registered nurse with clinical experience and obtain knowledge of insurance policies and healthcare regulations. Many employers prefer candidates with certifications such as the Certified Professional in Healthcare Quality (CPHQ) or related credentials. Gaining experience in case management or clinical review can improve your chances of entering the field.

What is the difference between Utilization Review Nurse vs Case Manager?

AspectUtilization Review NurseCase Manager
CredentialsRN license, certification in utilization review (e.g., URAC)RN license, case management certification (e.g., CCM)
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, insurance companies, community health settings
Employer & Industry UsagePrimarily in insurance and healthcare organizations for reviewing medical necessityIn healthcare and insurance for coordinating patient care and discharge planning

Utilization Review Nurses focus on evaluating the necessity and appropriateness of medical services, often working in insurance or healthcare settings. Case Managers coordinate patient care, discharge planning, and resource management. While both roles require RN licensure and related certifications, their primary responsibilities differ: UR Nurses review medical necessity, whereas Case Managers facilitate patient care and services.

Is it hard to be a utilization review nurse?

Being a utilization review nurse can be challenging due to the need for strong clinical knowledge, attention to detail, and the ability to make quick, accurate decisions based on medical records and guidelines. The job often involves working with insurance policies, documentation, and sometimes tight deadlines, but it also offers a structured environment and opportunities for certification and professional development.
What are the most commonly searched types of Utilization Review Nurse jobs in Decatur, GA? The most popular types of Utilization Review Nurse jobs in Decatur, GA are:
What are popular job titles related to Utilization Review Nurse jobs in Decatur, GA? For Utilization Review Nurse jobs in Decatur, GA, the most frequently searched job titles are:
What cities near Decatur, GA are hiring for Utilization Review Nurse jobs? Cities near Decatur, GA with the most Utilization Review Nurse job openings:
Infographic showing various Utilization Review Nurse job openings in Decatur, GA as of June 2026, with employment types broken down into 100% Full Time. Highlights an 60% In-person, and 40% Remote job distribution, with an average salary of $85,865 per year, or $41.3 per hour.
Inpatient Utilization Review Registered Nurse PRN / RN

Inpatient Utilization Review Registered Nurse PRN / RN

Emory Healthcare

Atlanta, GA

Other

Posted 10 days ago


Emory Healthcare rating

7.7

Company rating: 7.7 out of 10

Based on 210 frontline employees who took The Breakroom Quiz

163rd of 874 rated healthcare providers


Job description

Overview
Be inspired. Be rewarded. Belong. At Emory Healthcare.
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:
  • Comprehensive health benefits that start day 1
  • Student Loan Repayment Assistance & Reimbursement Programs
  • Family-focused benefits
  • Wellness incentives
  • Ongoing mentorship, development, leadership programs and... more!

Description
JOB DESCRIPTION: The Registry Utilization Review Nurse (PRN) is responsible for conducting medical necessity reviews by utilizing Milliman and Interqual Guidelines in conjunction with a review of the patient chart, clinical nursing judgement, and discussions with the attending physician and/or physician advisor. The UR RN (PRN) will perform utilization review by completing a timely and comprehensive review of all new observation and inpatient admissions for status designation as guided by criteria guidelines, patient presentation, and clinical nursing judgement. In addition, concurrent reviews will be completed as required by the payers, by accurately applying appropriate criteria sets. The UR RN (PRN) will ensure that all reviews are completed timely, accurately, and thoroughly by ensuring criteria guidelines applied are addressed in the clinical review. The UR RN (PRN) is responsible for timely communication to the Physicians and Interdisciplinary team as it relates to criteria guidelines and status designation on an individual patient basis. The UR RN (PRN) will ensure that patient hospital days are appropriately reviewed in order to obtain the appropriate authorization from the payer in an effort to ensure appropriate payment for services provided. The UR RN (PRN) will ensure that authorized days and patient actual LOS are reconciled in order to maximize reimbursement for the services provided. The UR RN (PRN) is responsible for real time communication and documentation of authorized, unauthorized or denied days to the Physician and the care team in order to reduce patient and hospital financial risk. The UR RN (PRN) will initiate and facilitate RN to RN discussion and/or Physician to Physician discussion with the payers in order to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services. The UR RN (PRN) will issue and administer notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures. The UR RN (PRN) attends interdisciplinary care planning rounds and serves as a liaison between the clinical care team, the revenue cycle, and the patient to ensure the continuity of patient care. The UR RN (PRN) serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to the utilization review process. The UR RN will (PRN) ensure compliance with all regulatory requirements as it relates to Government and Commercial Payers and designated Utilization Review Plans, as submitted to the State of Georgia. The UR RN (PRN) will ensure compliance with all third party payers and federal and state regulatory agencies. The UR RN (PRN) will ensure proper use of Case Management Systems and workflows.
MINIMUM QUALIFICATIONS: Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board. Bachelors degree in nursing preferred or actively being pursued. 2 years recent healthcare experience required. Must meet all quality and productivity expectations and successfully complete yearly competencies. Must be willing to work at least 4 shifts/mo. PHYSICAL REQUIREMENTS (MediumMax 25lbs): up to 25 lbs, 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 25 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.
Additional Details
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.

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