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Utilization Review Rn Jobs (NOW HIRING)

Mission Hospital

RN - Utilization Review

Tuba City, AZ · On-site

$2.7K/wk

Details Client Name Tuba City Regional Job Type Travel Offering Nursing Profession RN Specialty Utilization Review Job ID 37699865 Job Title RN - Utilization Review Weekly Pay $2772.28 Shift Details ...

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Remote Utilization Review RN

Detroit, MI · Remote

$35 - $39/hr

Utilization Review RN Contract Duration: 12+ months Job Location: 100% REMOTE License Requirements: MI Registered Nurse License Mandatory Requirements to Apply * Active, unrestricted Michigan ...

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How much do utilization review rn jobs pay per hour?

As of Sep 10, 2026, the average hourly pay for utilization review rn 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 is a utilization review RN?

A Utilization Review RN is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, collaborate with healthcare teams, and ensure that patient care meets established guidelines and payer requirements. Their role helps control costs, optimize care, and support compliance with healthcare regulations. Utilization Review RNs often work in hospitals, insurance companies, or managed care organizations.

How does a utilization review RN collaborate with physicians and other healthcare professionals during the patient care review process?

A Utilization Review RN works closely with physicians, case managers, and other healthcare team members to ensure that patients receive appropriate care while adhering to regulatory and insurance guidelines. This collaboration often involves discussing clinical findings, clarifying documentation, and negotiating care plans to meet both patient needs and payer requirements. Effective communication and teamwork are essential, as Utilization Review RNs frequently serve as liaisons between clinical staff and insurance representatives to facilitate timely authorizations and prevent unnecessary delays in patient care.

What are the key skills and qualifications needed to thrive as a utilization review RN, and why are they important?

To thrive as a Utilization Review RN, you need a current RN license, strong clinical assessment skills, and knowledge of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or ACM is often required. Excellent critical thinking, communication, and negotiation skills help you advocate for appropriate patient care while collaborating with providers and payers. These skills ensure cost-effective, quality care and compliance with regulatory standards in healthcare delivery.

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

AspectUtilization Review RnCase Manager
CredentialsRN license, certifications in utilization reviewRN license, certifications in case management
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, community agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of careCoordinating patient care and discharge planning

Utilization Review Rns primarily focus on evaluating the necessity of medical treatments, while Case Managers coordinate patient care and discharge planning. Both roles require RN licensure and certifications, but their daily responsibilities and work environments differ slightly, with Utilization Review Rns concentrating on review processes and Case Managers on patient advocacy and care coordination.

How to get into utilization review as a registered nurse?

To become a utilization review RN, you typically need a valid registered nurse license and experience in clinical settings. Additional certifications such as the Certified Professional in Healthcare Quality (CPHQ) or case management certification can enhance job prospects, and familiarity with electronic health records (EHR) systems is often required.
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Utilization Review RN jobs near you
Infographic showing various Utilization Review Rn job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Utilization Review Registered Nurse

Watertown, SD • On-site

Prairie Lakes Healthcare System
Health Care and Social Assistance • 501 - 1,000 employees
Learn more about Prairie Lakes Healthcare Systemexternal

$28.09 - $44.81/hr

Full-time, Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 27 days ago

Prairie Lakes Healthcare System rating

4.0

Company rating: 4.0 out of 10

Based on 7 frontline employees who took The Breakroom Quiz

Job description

Utilization Review Registered Nurse
Job Summary
Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones
POSITION SUMMARY
Wage: 28.09-44.81
On-site.
This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.
RESPONSIBILITIES
Develops and implements effective utilization review functions resulting in maintaining an average length of stay that is financially justified for hospital operations.
Reviews all inpatient and observation admissions within 24 hours for appropriateness based on approved criteria and standards, Monday through Friday. All weekend admissions are reviewed on the following Monday.
Contacts physicians as required for information to justify admission or continued stay the same day of questionable stay.
Refers all cases where necessity for admission is questionable or potential for denial is identified to the attending physician or his/her designee for appropriate action after notifying the Discharge Planning/Social Services manager.
Develops and maintains a system to monitor and review certification completion.
Maintains complete and accurate documentation which reflects the status of hospital utilization, numbers and categories of cases reviewed, and denials by fiscal intermediaries. Documents and reports back follow-up.
Reviews and follows through the appeal process for patient stay denials.
Other duties may be assigned.
JOB SPECIFICATIONS
Education and/or Experience
Bachelor’s degree required.
Five years of acute health care experience.
Two years experience related to utilization review preferred.
Certificates, Licenses, Registrations
Holds or is eligible for current nursing licensor in the State of South Dakota.
Mandatory Basic and Advanced Life Support Training per policy
Benefits
Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.
Additional benefits for those qualifying include:
  • Flexible Spending Account
  • Employee Assistance Program for mental health
  • Education Loan Program
  • Community discounts including the Prairie Lakes Wellness Center
Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.

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