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Utilization Review Nurse Jobs in Riverside, CA (NOW HIRING)

KPC Health

RN Case Manager (PD-Days)

Santa Ana, CA · On-site

UTILIZATION REVIEW AND DISCHARGE PLANNING * CA RN LICENSE & BLS CARD from American Heart Assoc. Benefits : * Medical, dental and vision coverage is provided for all full time and part time employees*

Colorwave Inc

Nurse Case Manager (RN)

Corona, CA · On-site

$75K - $160K/yr

Nurse Case Manager (RN) Hospitals on Incredible Health are actively hiring and accepting ... Clinical pathway, Navigator, or Utilization Review. Shift(s) available: day shift Job types ...

Colorwave Inc

Nurse Case Manager (RN)

Wildomar, CA · On-site

Nurse Case Manager (RN) Hospitals on Incredible Health are actively hiring and accepting ... Clinical pathway, Navigator, or Utilization Review. Shift(s) available: day shift Job types ...

UHS

CASE MANAGER (RN/LIC) - Full Time

Wildomar, CA

Two (2) years' experience clinical Case Management or Utilization Review preferred Completion of an accredited Registered Nursing program. REQUIRED LICENSURE / CERTIFICATIONS Current California ...

UHS

CASE MANAGER (RN/LIC) - Full Time

Wildomar, CA · On-site

Two (2) years' experience clinical Case Management or Utilization Review preferred Completion of an accredited Registered Nursing program. REQUIRED LICENSURE / CERTIFICATIONS Current California ...

Oso Home Care

Authorization Specialist

Irvine, CA · On-site

$23 - $25.90/hr

Develop professional working relationships with payer representatives and utilization review nurses. * Respond to requests for additional information. * Participate in peer-to-peer review ...

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All JobsUtilization Review Nurse JobsUtilization Review Nurse Jobs in Riverside, CA

Utilization Review Nurse information

See Riverside, CA salary details

$22

$44

$71

How much do utilization review nurse jobs pay per hour?

As of Aug 7, 2026, the average hourly pay for utilization review nurse in Riverside, CA is $44.11, according to ZipRecruiter salary data. Most workers in this role earn between $34.86 and $50.67 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 much do utilization review nurses make?

Utilization review nurses in Texas typically earn an average annual salary of around $70,000 to $85,000, depending on experience, certifications, and employer. Salaries can vary based on healthcare setting, location, and workload, with some experienced nurses earning higher wages or additional benefits.

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.

More about Utilization Review Nurse jobs
What are the most commonly searched types of Utilization Review Nurse jobs in Riverside, CA? The most popular types of Utilization Review Nurse jobs in Riverside, CA are:
What are popular job titles related to Utilization Review Nurse jobs in Riverside, CA? For Utilization Review Nurse jobs in Riverside, CA, the most frequently searched job titles are:
What job categories do people searching Utilization Review Nurse jobs in Riverside, CA look for? The top searched job categories for Utilization Review Nurse jobs in Riverside, CA are:
What cities near Riverside, CA are hiring for Utilization Review Nurse jobs? Cities near Riverside, CA with the most Utilization Review Nurse job openings:
Utilization Review Nurse jobs near you
Infographic showing various Utilization Review Nurse job openings in Riverside, CA as of August 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 $91,752 per year, or $44.1 per hour.

Concurrent Case Management RN

LSMA Management Inc

San Bernardino, CA • On-site

$85K - $100K/yr

Full-time

Re-posted 6 days ago

Job description

Description

JOB SUMMARY:

The Concurrent Case Management RN is responsible for concurrent utilization review, care coordination, and discharge planning for inpatient members within a managed care environment. This role serves as a clinical resource to care management staff, supports compliance with regulatory and health plan requirements, and collaborates with providers, hospitals, and interdisciplinary teams to ensure medically necessary, cost-effective, and quality care.

The position performs medical necessity reviews using established criteria, monitors length of stay, facilitates transitions of care, and identifies opportunities to improve outcomes and reduce avoidable utilization.


Requirements

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum:  High School diploma or equivalent required. Graduate of an accredited Registered Nursing program.

Preferred: Bachelor of Science in Nursing (BSN).


Experience 

Minimum: Three (3) years of clinical nursing experience; 1-2 years in utilization management, case management, or managed care.

Preferred: Experience in a health plan, MSO, IPA, or acute setting with utilization review responsibilities.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current State Registered Nursing License.

Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred.

Skills, Knowledge & Abilities

Knowledge of utilization management standards (CMS, DMHC, InterQual/Milliman) 

Strong clinical assessment and critical thinking skills 

Understanding of managed care and value-based care models 

Excellent written and verbal communication skills 

Ability to manage multiple cases and meet regulatory deadlines 

Proficiency with electronic medical records (EMR) and Microsoft Office applications 

Ability to work independently and collaboratively in a fast-paced environment 

Strong organizational and time management skills


PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this position, with or without reasonable accommodation. The role primarily involves sedentary work, including extended periods of sitting, computer use, and communication. The employee may occasionally be required to stand, walk, bend, and lift items up to 20 pounds. The position requires the ability to review detailed medical documentation, perform data entry, and maintain sustained concentration and attention to detail. The employee must be able to communicate effectively through verbal, written, and electronic means, including phone and video communication. Occasional travel to healthcare facilities or office locations may be required based on business needs.


PAY RANGE 

$85,000 - $100,000 / annually 

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