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

Kaiser Permanente

RN, Targeted Review

Atlanta, GA · On-site

$40.35/hr

The activities will include telephonic review for medical necessity of the RN designated targeted ... Monitors utilization trends in the market area, keeping appropriate management informed. Initiates ...

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All JobsUtilization Review Nurse JobsUtilization Review Nurse Jobs in Decatur, GA

Utilization Review Nurse information

See Decatur, GA salary details

$20

$41

$67

How much do utilization review nurse jobs pay per hour?

As of Jul 15, 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.

How to make $300,000 as a nurse?

To earn $300,000 as a Utilization Review Nurse, professionals typically need extensive experience, advanced certifications such as CCM or ANCC, and may work in high-paying healthcare settings or take on additional responsibilities like case management or leadership roles. Working overtime, specializing in complex cases, or pursuing advanced degrees can also increase earning potential.

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.

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, candidates typically need a registered nurse (RN) license and experience in clinical settings. Additional certifications such as Certified Professional in Healthcare Quality (CPHQ) or case management credentials can improve job prospects, and familiarity with medical records, insurance policies, and utilization review software is often required.

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 involves reviewing medical records and determining appropriate care levels, which requires strong clinical knowledge, attention to detail, and good communication skills. The job can be demanding due to tight deadlines, the need for accuracy, and the responsibility of making critical decisions that impact patient care and insurance processes.
More about Utilization Review Nurse jobs
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What cities near Decatur, GA are hiring for Utilization Review Nurse jobs? Cities near Decatur, GA with the most Utilization Review Nurse job openings:
Utilization Review Nurse jobs near you
Infographic showing various Utilization Review Nurse job openings in Decatur, GA as of July 2026, with employment types broken down into 2% As Needed, 62% Full Time, 19% Part Time, 1% Temporary, and 16% Contract. Highlights an 98% Physical, and 2% Remote job distribution, with an average salary of $85,865 per year, or $41.3 per hour.

Workers' Compensation Delegated Claims Audit Specialist

MSIG Holdings USA, Inc.

Atlanta, GA

$22.25 - $30.75/hr

Full-time

Posted 20 days ago

Job description

MSIG USA continues to grow!

Company Overview:

MSIG USA is the US-based subsidiary ofMS&AD Insurance Group Holdings, Inc., one of the world's top P&C carriers and a global Class 15 insurer, with A+ ratings and a reach that spans 40+ countries and regions. Leveraging our 350-year heritage, MSIG USA brings the financial strength, expertise, and global footprint to offer commercial insurance solutions that address your business's unique risks.

Position Summary

The Workers' Compensation Delegated Claims Audit Specialist conducts comprehensive audits of workers' compensation claims administered under delegated authority by third-party administrators (TPAs) on behalf of the company and its insureds/clients. The role evaluates the quality, accuracy, compliance, and financial integrity of delegated claim handling, ensuring adherence to company guidelines, client-specific service instructions, jurisdictional statutes, and industry best practices. Findings are used to drive corrective action, mitigate loss leakage, and support TPA performance management.

Key Responsibilities

  • Perform file-level and program-level audits of workers' compensation claims handled under delegated authority by TPAs, applying standardized scoring criteria and audit protocols.

  • Evaluate compliance with multi-jurisdictional WC statutes, regulations, mandatory filing/EDI requirements, and state fee schedules.

  • Assess accuracy of indemnity benefit calculations, including average weekly wage, waiting periods, TTD/TPD/PPD/PTD, and benefit rate application.

  • Review medical management activities - bill review, PPO penetration, utilization review, nurse case management, and pharmacy/formulary controls.

  • Evaluate reserve adequacy, reserve rationale, and timeliness of reserve adjustments against exposure.

  • Audit investigation quality, compensability decisions, three-point contact, and timeliness of initial benefit payments.

  • Review litigation management, defense counsel oversight, litigation budgets, and settlement authority compliance.

  • Assess subrogation/recovery identification and pursuit, including excess/reinsurance and Second Injury Fund recovery where applicable.

  • Identify fraud indicators and evaluate appropriateness of SIU referrals.

  • Verify Medicare compliance, including Section 111 reporting, conditional payment resolution, and MSA handling where applicable.

  • Confirm adherence to delegated authority limits, claim handling guidelines, and escalation/reporting requirements.

  • Document audit results in clear written reports with scoring, root-cause analysis, and actionable corrective recommendations.

  • Track remediation, validate corrective actions, and conduct re-audits as needed.

  • Identify trends and systemic handling issues across files; report findings to leadership and contribute to TPA scorecards and stewardship reviews.

  • Support new TPA onboarding/baseline audits and client-driven special audits.

Required Qualifications

  • 5+ years of workers' compensation claims adjusting and/or claims audit experience.

  • Demonstrated multi-jurisdictional WC handling knowledge across multiple states.

  • Strong understanding of statutory benefits, reserving methodology, medical management, and litigation/settlement practices.

  • Adjuster license(s) as required by applicable jurisdictions (or ability to obtain).

  • Proficiency with claims systems, audit tools, and Microsoft Office (Excel, Word).

Preferred Qualifications

  • Bachelor's degree.

  • Professional designations such as WCCP, AIC/AIC-M, ARM, SCLA, or CPCU.

  • Prior experience auditing TPAs or working within a carrier/self-insured delegated claims oversight function.

  • Experience with EDI/state reporting requirements and Medicare Secondary Payer compliance.

Core Competencies

  • Strong analytical and critical-thinking skills with high attention to detail.

  • Excellent written communication; able to produce clear, defensible audit reports.

  • Sound judgment and objectivity; comfortable delivering constructive findings.

  • Ability to manage multiple audits independently and meet deadlines.

  • Professionalism and tact in interactions with TPAs, clients, and internal stakeholders.

It's an exciting time for our company and a great opportunity to join a financially sound and growing global insurance group!


It is the policy of MSIG USA to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, MSIG USA will provide reasonable accommodations for qualified individuals with disabilities.

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