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Utilization Review Rn information

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$19

$38

$62

How much do utilization review rn jobs pay per hour?

As of Jul 14, 2026, the average hourly pay for utilization review rn in Tennessee is $38.38, according to ZipRecruiter salary data. Most workers in this role earn between $30.34 and $44.09 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.
What are the most commonly searched types of Utilization Review Rn jobs in Tennessee? The most popular types of Utilization Review Rn jobs in Tennessee are:
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Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Tennessee as of July 2026, with employment types broken down into 1% As Needed, 80% Full Time, 13% Part Time, 2% Temporary, and 4% Contract. Highlights an 91% Physical, 2% Hybrid, and 7% Remote job distribution, with an average salary of $79,822 per year, or $38.4 per hour.

VP of Utilization Review

ODYSSEY BEHAVIORAL GROUP

Franklin, TN • On-site, Remote

Full-time

Re-posted 15 days ago

Job description

Position Summary
The Vice President of Utilization Review (VP of UR) provides strategic and operational leadership for the enterprise-wide Utilization Review function across all behavioral health service lines and levels of care. This executive leader is responsible for developing, standardizing, optimizing, and overseeing utilization management practices that support quality care, appropriate reimbursement, regulatory compliance, payer relationships, and organizational financial performance.
The VP of UR partners closely with Executive Leadership, Clinical Operations, Revenue Cycle, Admissions, Nursing, Compliance, Business Development, and Finance to ensure utilization management processes align with organizational goals, evidence-based practices, and payer requirements. This role is responsible for driving performance improvement initiatives related to authorizations, denials management, length of stay optimization, appeals, documentation integrity, and payer strategy.
The VP of UR serves as the enterprise subject matter expert for utilization management and develops scalable systems, reporting structures, KPIs, and accountability processes to support continued organizational growth and operational excellence.
Relationships and Contacts
Within the organization: Maintains frequent and collaborative working relationships with the Chief Clinical Officer, Executive Leadership, Divisional CEOs, Chief Financial Officer, Revenue Cycle leadership, Business Development, Admissions, Nursing leadership, Medical leadership, Compliance, Risk Management, Operations leadership, and all clinical team members across the organization.
Outside the organization: Develops and maintains strategic relationships with insurance organizations, managed care companies, external review organizations, payer representatives, referral partners, vendors, and consultants, as appropriate.
Position Responsibilities
Essential Responsibilities
  1. Provides executive oversight and strategic direction for all enterprise Utilization Review operations across multiple facilities, service lines, and states.
  2. Develops and implements standardized enterprise-wide UR processes, workflows, policies, and documentation standards to improve operational consistency and payer outcomes.
  3. Oversees authorization management, concurrent review processes, denial prevention strategies, appeals management, retrospective reviews, and payer escalation processes.
  4. Partners with Clinical, Nursing, Admissions, and Revenue Cycle teams to ensure documentation supports medical necessity, level of care determinations, and reimbursement optimization.
  5. Develops enterprise KPI dashboards and reporting structures related to denials, overturn rates, authorization timeliness, payer trends, reimbursement performance, length of stay management, and utilization efficiency.
  6. Identifies trends, gaps, and opportunities within utilization management processes and leads performance improvement initiatives to enhance operational and financial outcomes.
  7. Collaborates with executive leadership regarding payer contracting strategy, authorization challenges, network access issues, and value-based care initiatives.
  8. Serves as an organizational expert regarding payer requirements, medical necessity criteria, utilization management regulations, and behavioral health reimbursement practices.
  9. Oversees recruitment, onboarding, training, mentorship, performance management, and leadership development for enterprise UR leadership and staff.
  10. Conducts regular audits and quality reviews to ensure compliance with regulatory requirements, payer expectations, and organizational standards.
  11. Develops escalation pathways and support structures for complex cases, difficult payer interactions, and high-risk authorization issues.
  12. Leads enterprise education initiatives related to documentation integrity, medical necessity standards, payer trends, and authorization best practices.
  13. Collaborates with Information Technology and EHR leadership to optimize utilization review workflows, reporting capabilities, automation opportunities, and data integrity.
  14. Supports organizational growth initiatives, acquisitions, new program development, and expansion strategies through scalable utilization management processes.
  15. Participates in executive meetings, operational reviews, and strategic planning initiatives as a key organizational leader.
  16. Maintains strict confidentiality of all company, departmental, patient, payer, and healthcare provider information.
  17. Reports enterprise risks, payer concerns, and operational barriers to executive leadership with recommendations for resolution and mitigation.

Education and Experience
Bachelor's degree required, master's degree in nursing, Healthcare Administration, Business Administration, or related healthcare field preferred. Clinical licensure preferred (RN, LCSW, LPC, LMFT, or comparable behavioral health licensure). Requires a minimum of seven (7) years of progressive Utilization Review leadership experience within behavioral health, including large multi-site or enterprise oversight responsibilities. Previous experience developing KPIs, reporting analytics, dashboards, and executive-level operational presentations is required.
Physical Requirements
  • While performing the duties of this job, the employee must communicate with internal and external stakeholders and vendors.
  • Tolerant to various noise levels: noise level in the work environment varies - may be quiet to moderate noise levels.
  • Job performance will require the ability to move throughout the building as well as sit or remain stationary for extended periods of time.
  • While performing the duties of this job, the employee may be required to talk or hear, sit, stand, walk, and reach.
  • Ability to travel by various forms of transportation, including automobiles and airplane.

Additional Requirements
  • Position requires incumbent to have a valid driver's license and acceptable driving record.
  • Clearance of TB test, and any other mandatory state/federal requirements.

Skill Competencies
  • Demonstrates executive leadership and strategic planning capabilities.
  • Demonstrates the ability to lead enterprise-wide operational change and process improvement initiatives.
  • Demonstrates extensive knowledge of behavioral health levels of care, medical necessity criteria, payer operations, reimbursement methodologies, and regulatory requirements.
  • Demonstrates experience leading large-scale operational improvement initiatives and enterprise standardization efforts.
  • Demonstrates a strong understanding of managed care contracting, denial management, appeals processes, and payer negotiation strategies.
  • Demonstrates strong financial acumen with understanding of reimbursement, payer strategy, and revenue optimization.
  • Demonstrates ability to successfully function under pressure in critical and rapidly changing situations.
  • Demonstrates ability to effectively manage conflict, escalation, and crisis situations.
  • Demonstrates strong analytical, problem-solving, and decision-making skills.
  • Demonstrates exceptional organizational and project management skills.
  • Demonstrates excellent interpersonal, relationship-building, and executive communication skills.
  • Demonstrates the ability to influence cross-functional teams and build organizational alignment.
  • Demonstrates a prominent level of discretion, professionalism, and accountability.
  • Demonstrates strong diligence and follow-through.
  • Demonstrates proficiency with Microsoft Office programs, reporting systems, EHR platforms, and data analytics tools.
  • Consistently demonstrates and models alignment with company mission, values, and leadership expectations.

Odyssey Behavioral Healthcare, LLC provides equal employment opportunities without regard to race, color, creed, ancestry, national origin, ethnicity, sex, gender, sexual orientation, marital status, religion, age, disability, gender identity, genetic information, service in the military, or any other characteristic protected under applicable federal, state, or local law. Equal employment opportunities apply to all terms and conditions of employment. Odyssey reserves the right to modify, interpret, or apply this job description in any way the organization desires. This job description in no way implies that these are the only duties, including essential duties, to be performed by the employee occupying this position. Reasonable accommodations may be made to reasonably accommodate qualified individuals with disabilities. This job description is not an employment contract, implied or otherwise. The employment relationship remains "At-Will."

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