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Utilization Review Nurse Jobs (NOW HIRING)

UNC Health Careers

Utilization Review Nurse

Kinston, NC · On-site

$32.48 - $38.98/hr

To accomplish these goals, the UR, Nurse applies established criteria to evaluate the ... review and proactively resolving care, service, or transition of care delays/issues as necessary ...

UK St Claire

Utilization Review Nurse

Morehead, KY · On-site +1

Supports utilization review processes by planning, analyzing data, and setting goals to ensure ... Education Requirement Bachelor's degree in nursing, or a related field Experience Requirement 2+ ...

UK St Claire

Supports utilization review processes by planning, analyzing data, and setting goals to ensure ... Generates and interprets reports for physicians, nursing, and ancillary services. Coordinates with ...

VIVA USA INC

Utilization Review Nurse

Albuquerque, NM · On-site +1

Review Service Requests, Collect Clinical And Non-Clinical Data, Verify Eligibility, Determine ... Utilization Management Requirements And Operational Procedures To Members, Providers And Facilities ...

Houston Methodist

At Houston Methodist, the Utilization Review Nurse (URN) PRN position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical ...

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How much do utilization review nurse jobs pay per hour?

As of Jun 17, 2026, the average hourly pay for utilization review nurse 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 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.
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Utilization Review Nurse jobs near you
Infographic showing various Utilization Review Nurse job openings in the United States as of June 2026, with employment types broken down into 100% Full Time. Highlights an 50% In-person, and 50% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Utilization Review Nurse

Utilization Review Nurse

UNC Health Careers

Kinston, NC • On-site

$32.48 - $38.98/hr

Other

Posted 17 days ago

Job description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:
This position facilitates utilization management processes to support the right care is provided at the right place at the right time. To accomplish these goals, the UR, Nurse applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the care team. This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team, patient, family, and others. Communicates with physicians for appropriate documentation to support authorization of services.


Responsibilities:
Patients/Families, Hospital staff, Medical staff, Community agencies, and Insurance Companies are served by conducting interpersonal relationships in a manner that projects a positive image of the department and hospital. All contacts with customers are friendly, helpful and courteous.


Other Information

Other information:
Qualifications
EDUCATION REQUIREMENTS
Graduate from an accredited school of nursing, BSN preferred.
PROFESSIONAL EXPERIENCE REQUIREMENT
Five (5) years of health care experience as a Registered Nurse.
LICENSURE/REGISTRATION/CERTIFICATION
Licensed to practice as a Registered Nurse in the state of North Carolina.
KNOWLEDGE, SKILLS AND ABILITIES REQUIREMENTS
Strong assessment and critical thinking skills.
PHYSICAL REQUIREMENT
Standing, Walking, Sitting, Reaching, Talking, Seeing, Hearing, Tasting, Smelling, Carrying, Pushing, Pulling, Lifting, and Moving.


Job Details

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: Care Management

Work Type: Per Diem

 Salary Range: $32.48 - $38.98 per hour (Minimum to Midpoint )

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Variable

Location of Job: US:NC:Kinston

Exempt From Overtime: Exempt: No


Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.

Employment Type:

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