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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 ...

Harborview Thomasville

MDS Coordinator RN

Thomasville, GA

$30.25 - $36.50/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 Jun 14, 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 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.

How do I become a utilization review RN?

To become a utilization review RN, you typically need to hold a valid registered nurse (RN) license and have experience in clinical nursing. Additional certifications such as the Certified Professional in Healthcare Quality (CPHQ) or Utilization Review Certification (URAC) can enhance job prospects, and strong knowledge of medical coding, insurance policies, and healthcare regulations is important.

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 does an RN utilization review do?

An RN utilization review evaluates medical records and treatment plans to determine the appropriateness, necessity, 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.

How to make $300,000 a year as a nurse?

To earn $300,000 annually as a Utilization Review RN, professionals typically need extensive experience, advanced certifications such as CCM or ANCC, and may work in high-paying settings like insurance companies or healthcare consulting firms. Increasing specialization, taking on leadership roles, or working overtime can also boost income, but reaching this level often requires a combination of skills, experience, and strategic career moves.

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 CCM or ANCC, and working in high-paying settings like insurance companies or managed care organizations. Advanced skills in case management, strong clinical knowledge, and sometimes working overtime or in leadership roles can also contribute to higher earnings.

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 100% Full Time. Highlights an 100% In-person job distribution, with an average salary of $74,260 per year, or $35.7 per hour.
Utilization Management Director - RN Required - Remote

Utilization Management Director - RN Required - Remote

Northeast Georgia Health System

Gainesville, GA • On-site, Remote

Full-time

Posted 4 days ago

Northeast Georgia Health System rating

7.5

Company rating: 7.5 out of 10

Based on 149 frontline employees who took The Breakroom Quiz

223rd of 872 rated healthcare providers

Job description

Job Category:
Executive Leadership, Revenue Cycle
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
The Director of Utilization Management (UM) is responsible for leading and managing the Utilization Management (UM) functions at Northeast Georgia Medical Center. This position plays a critical role in ensuring correct status assignment, optimizing reimbursement, minimizing denials, improving case mix index (CMI), and ensuring appropriate utilization of hospital resources. The Director works collaboratively with hospital leadership, physicians, case management, finance, and compliance teams to enhance quality reporting, patient outcomes, and financial integrity. This role serves as a key liaison between clinical and financial operations, ensuring a seamless integration of documentation integrity with utilization management to drive efficiency, compliance, and revenue cycle optimization.
Minimum Job Qualifications
  • Licensure or other certifications: Registered Nurse, UR specific certification preferred (CCM, ACM, CPUR)
  • Educational Requirements: Bachelors Degree
  • Minimum Experience: Minimum of 7 years UR with progressive Revenue Cycle leadership experience of 2 or more years.
  • Other:

Preferred Job Qualifications
  • Preferred Licensure or other certifications:
  • Preferred Educational Requirements: Master's Degree in Nursing or other health related field preferred
  • Preferred Experience:
  • Other:

Job Specific and Unique Knowledge, Skills and Abilities
  • Proven ability to lead teams, manage budgets, and implement strategic initiatives.
  • Strong ability to educate and influence physicians, staff, and leadership on UM best practices.
  • Experience in data analysis, KPI tracking, and performance improvement strategies.
  • Expertise in medical necessity criteria, payer regulations, and revenue cycle principles.
Essential Tasks and Responsibilities
  • Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards.
  • Work closely with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance.
  • Monitor and analyze key performance indicators (KPIs), financial goals, and length of stay (LOS) metrics to drive performance improvements.
  • Recruit, train, and manage a high-performing UM team, ensuring operational alignment with hospital objectives.
  • Manage departmental budgets, ensuring financial responsibility and resource allocation
  • Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement.
  • Foster strong relationships with internal and external stakeholders, including hospital executives, physicians, and payers.
  • Provide data-driven insights and strategic recommendations to hospital leadership regarding UM performance.
  • Act as the operational leader for process improvement initiatives related to utilization management, and revenue cycle optimization.
  • Work closely with Physician Advisors to develop and revise policies and procedures related to clinical status determination, medical necessity, denials and appeals, and physician education.
  • Review daily, weekly and monthly reports to monitor and analyze performance of UM departments, assess data against KPI standards and goals, and identifies trends to make adjustments as indicated. Keeps leadership, staff, and clinical staff (where appropriate) informed.
  • Oversees UM working closely with Case Management and other members of the interdisciplinary team to ensure effective collaboration for length of stay and throughput.
  • Communicate with and educate physicians and other key stake holders regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care.
  • Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently.
  • Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/physician performance and anticipating payer and managed care demands.
  • Actively participates as the operational leader for UM in committees including but not limited to MRUR; Compliance; Policy and Procedures; and Quality
  • Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
Physical Demands
  • Weight Lifted: Up to 20 lbs, Frequently 31-65% of time
  • Weight Carried: Up to 20 lbs, Frequently 31-65% of time
  • Vision: Moderate, Frequently 31-65% of time
  • Kneeling/Stooping/Bending: Occasionally 0-30%
  • Standing/Walking: Constantly 66-100%
  • Pushing/Pulling: Constantly 66-100%
  • Intensity of Work: Occasionally 0-30%
  • Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

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About Northeast Georgia Health System

Sourced by ZipRecruiter

Northeast Georgia Health System (NGHS) is a not-for-profit community health system dedicated to improving the health and quality of life of the people of Northeast Georgia. Through the services of a medical staff of more than 800 physicians, the residents of Northeast Georgia enjoy access to the state’s finest and most comprehensive medical services. It is our mission to improve the health of our community in all we do.

Industry

Health care and social assistance

Company size

5,001 - 10,000 Employees

Headquarters location

Gainesville, GA, US

Year founded

1951

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