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Utilization Review Rn Jobs in Georgia (NOW HIRING)

KARNA LLC

Medical Claims Review Nurse

Atlanta, GA · On-site

Registered nurse (RN) * BSN or BA/BS required; Experience in lieu of degree will be considered * 5 years of experience in acute care settings * 2 years in Utilization Review (UR)/, Utilization ...

Roselane Health Center by Harborview

MDS-RN

Marietta, GA · On-site

$43 - $45/hr

Conduct and participate in IDT meetings including: daily PDPM, weekly CMI, Utilization Review ... Active RN license in good standing in the state of practice * Experience in skilled nursing and ...

Roselane Health Center by Harborview

MDS-RN

Marietta, GA · On-site

$43 - $45/hr

Conduct and participate in IDT meetings including: daily PDPM, weekly CMI, Utilization Review ... Active RN license in good standing in the state of practice * Experience in skilled nursing and ...

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Utilization Review Rn information

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$35

$58

How much do utilization review rn jobs pay per hour?

As of Jul 6, 2026, the average hourly pay for utilization review rn in Georgia is $35.70, according to ZipRecruiter salary data. Most workers in this role earn between $28.22 and $41.01 per hour, depending on experience, location, and employer.

How to get into utilization review as a nurse?

To become a utilization review RN, candidates typically need a valid nursing license and experience in clinical settings. Additional certifications such as Certified Professional in Healthcare Quality (CPHQ) or case management credentials can enhance prospects, and familiarity with electronic health records and insurance policies is beneficial.

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.

How to make $300,000 as a nurse?

A Utilization Review RN can earn $300,000 by gaining extensive experience, obtaining certifications such as Certified Review Officer (CRO), working in high-paying settings like insurance companies or managed care organizations, and taking on leadership or specialized roles that offer higher compensation. Advanced skills in clinical assessment, documentation, and understanding of healthcare policies can also contribute to higher earnings.

What does an RN utilization review do?

An RN utilization review evaluates medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They ensure compliance with insurance policies and clinical guidelines, often using electronic health records and requiring knowledge of coding and documentation standards. This role supports cost-effective patient care and involves collaboration with healthcare providers and insurance companies.

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 make $150,000 as a nurse?

A Utilization Review RN can earn $150,000 by gaining extensive experience, obtaining certifications such as Certified Review Officer (CRO), working in high-demand settings, and possibly taking on leadership or specialized roles. Increasing your workload, working overtime, or pursuing advanced education can also contribute to higher earnings within this field.

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.
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Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Georgia as of June 2026, with employment types broken down into 81% Full Time, and 19% Part Time. Highlights an 94% In-person, and 6% Remote job distribution, with an average salary of $74,260 per year, or $35.7 per hour.
Medical Claims Review Nurse

Medical Claims Review Nurse

KARNA LLC

Atlanta, GA • On-site

Full-time

Posted 25 days ago

Job description

Description:

Are you passionate about making a difference? The World Trade Center (WTC) Health Program provides support to those impacted by 9/11. This position for a medical claims review nurse on the World Trade Center (WTC) Health Program will have a direct impact on members of the program. The nurse will be responsible for reviewing claims that pend to Medical Review to ensure all services are medically necessary as well as analyzing and responding to provider appeals.


Responsibilities:


o Analyzing claims issues for claims pended to Medical Review

o Performing evidence-based research

o Determining whether claims issues can be resolved internally or require client review

o Making recommendations to the client based on research and medical knowledge

o Presenting findings to the client on a weekly basis

o Reporting on claims metrics

  • Reviews and responds to medical claims appeals.
  • Coordinates with the Clinical Centers of Excellence (CCEs) to obtain medical claims records and other needed documentation to resolve claims’ issues.
  • Researches medical code pricing using the FECA fee schedule and other pricing methodologies.
  • Conducts medical claims audits to ensure quality control.
  • Documents Medical Management processes, including medical claims review.
  • Completes ad hoc research for the client.
Requirements:
  • Registered nurse (RN)
  • BSN or BA/BS required; Experience in lieu of degree will be considered
  • 5 years of experience in acute care settings
  • 2 years in Utilization Review (UR)/, Utilization Management (UM), and/or Case Management
  • Experience with claims review in the acute care setting
  • Certified Case Manager (CCM), Accredited Case Manager (ACM), or similar certification preferred
  • Knowledge of Federal programs and payors, including CMS, OWCP, and Tricare preferred
  • Must be familiar with coding, including ICD-10, CPT and HCPCS
  • Experience with Quality Assurance review of medical claims preferred
  • Experience with analyzing data and reporting on UR trends
  • Experience with appeals and denials
  • Knowledge of transitions of care
  • Ability to identify areas to improve cost, quality, and utilization of care within a population
  • Ability to maintain HIPAA compliance
  • Well-versed in Microsoft Office products, including SharePoint
  • Ability to obtain and maintain appropriate security clearance
  • Knowledge of workers compensation claims is a plus


If you’re ready to take on a role that combines your clinical expertise with a passion for service, we’d love to hear from you. Apply now and become a vital part of the World Trade Center Health Program!


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