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Utilization Review Nurse Jobs in Rio Rancho, NM (NOW HIRING)

UNM HOSPITALS

CLINICAL DOCUMENT SPECIALIST RN

Albuquerque, NM · On-site

$33.75 - $45.25/hr

... Utilization Review/Case Management meetings as requested * COMMUNICATION - Communicate with ... Nursing Experience: * Essential: 1 year directly related experience * Nonessential: Documentation ...

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Utilization Review Nurse information

See Rio Rancho, NM salary details

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$65

How much do utilization review nurse jobs pay per hour?

As of Sep 13, 2026, the average hourly pay for utilization review nurse in Rio Rancho, NM is $40.01, according to ZipRecruiter salary data. Most workers in this role earn between $31.63 and $45.96 per hour, depending on experience, location, and employer.

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 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 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 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 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.

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Utilization Review Nurse jobs near you
Infographic showing various Utilization Review Nurse job openings in Rio Rancho, NM as of September 2026, with employment types broken down into 5% As Needed, 61% Full Time, 5% Part Time, and 29% Contract. Highlights an 95% In-person, and 5% Remote job distribution, with an average salary of $83,222 per year, or $40 per hour.

Clinical Case Manager - RN

Albuquerque, NM • On-site

Career Land Center, LLC
Recruiting and Staffing Services • 1 - 10 employees
Learn more about Career Land Center, LLCexternal

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 9 days ago

Job description

A Healthcare Facility is seeking a Clinical Access Case Manager (RN) to support hospital-wide utilization management and care coordination. 

Position Overview

This role focuses on clinical access and utilization review across all inpatient populations. The Case Manager applies established criteria to support appropriate admission status, level-of-care decisions, and safe transitions throughout the patient stay. 

Work is completed in collaboration with physicians, nurses, and interdisciplinary teams throughout the facility, using InterQual criteria and Cerner-based systems to guide decision-making and documentation.

Key Responsibilities

• Perform utilization review and clinical access evaluations for inpatient admissions
• Apply InterQual criteria to support level-of-care determinations
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate patient placement
• Support timely and appropriate care transitions across the continuum
• Identify opportunities to improve utilization, throughput, and resource management
• Document clinical reviews and care decisions accurately within Cerner systems
• Communicate findings and recommendations clearly to clinical teams
• Support compliance with regulatory and payer requirements related to utilization management
• Assist with coordination of patient flow across hospital departments

Qualifications

• Associate degree in Nursing or higher required
• Minimum of 2 years of acute care experience required
• Experience with InterQual and utilization review/management required
• Experience with CCM, ACM, or Milliman criteria preferred
• Basic Life Support (BLS) required upon submission
• Active New Mexico or compact RN license required prior to start (open to candidates without current licensure at time of application)
• Strong understanding of acute care workflows and hospital-based care coordination

Benefits

• Comprehensive medical, dental, and vision coverage
• Paid time off and holiday benefits
• Retirement savings program
• Continuing education and certification support
• Opportunity to work in a hospital-wide utilization management role within a multi-service acute care facility
• Collaborative interdisciplinary environment focused on improving patient flow and care efficiency
• Sign-on incentive available