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Utilization Review Rn Jobs in Texas (NOW HIRING)

Ascension

Registered Nurse Utilization Review

Austin, TX · Remote

$78K - $110K/yr

... utilization review reports and performance metrics as needed. What You Will Need Licensure / Certification / Registration: * Licensed Registered Nurse credentialed from the Texas Board of Nursing or ...

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Utilization Review Rn information

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$39

$64

How much do utilization review rn jobs pay per hour?

As of Jul 19, 2026, the average hourly pay for utilization review rn in Texas is $39.39, according to ZipRecruiter salary data. Most workers in this role earn between $31.15 and $45.24 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 Texas? The most popular types of Utilization Review Rn jobs in Texas are:
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Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Texas as of July 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, 2% Contract, and 1% Nights. Highlights an 91% Physical, 2% Hybrid, and 7% Remote job distribution, with an average salary of $81,936 per year, or $39.4 per hour.
Utilization Review Registered Nurse

Utilization Review Registered Nurse

Texas Institute for Surgery

Dallas, TX • On-site

Other

Posted 11 days ago

Job description

Utilization Review Registered Nurse

Texas Institute for Surgery LL SURG - Dallas, TX 75231

Description

The Utilization Review Registered Nurse is responsible for ensuring appropriate patient status, medical necessity, and payer compliance through prospective, concurrent, and retrospective review.

This role serves as the clinical lead for utilization management and a key contributor to denial prevention, partnering closely with Denial Management and Revenue Cycle teams to proactively identify, mitigate, and reduce denial risk. The role also collaborates closely with Case Management to align patient status, authorization, and progression of care with payer requirements.

Essential Duties and Responsibilities:

  1. Conduct admission and concurrent medical necessity reviews using InterQual or Milliman criteria.
  2. Ensure appropriate patient status designation, including inpatient versus observation level of care.
  3. Obtain, validate, and maintain payer authorizations and required notifications.
  4. Identify, escalate, and help mitigate cases at risk for denial.
  5. Collaborate with physicians to support accurate and complete clinical documentation.
  6. Serve as a liaison with payers during concurrent reviews, authorization inquiries, and peer-to-peer discussions.
  7. Partner with Denial Management and Revenue Cycle teams to identify denial trends and implement prevention strategies.
  8. Maintain accurate and timely documentation of utilization review activities.
  9. Ensure compliance with CMS, regulatory, and payer requirements.
  10. Perform daily census reviews to validate patient status, medical necessity, and authorization requirements.
  11. Prioritize high-risk cases, including extended observation stays, high-cost encounters, and incomplete or pending authorizations.
  12. Lead real-time denial prevention efforts through early identification of documentation, authorization, and medical necessity gaps.
  13. Prepare clinical information and support peer-to-peer reviews by aligning documentation with payer criteria.
  14. Provide timely feedback to physicians regarding documentation opportunities that may impact medical necessity determinations and reimbursement.
  15. Monitor patient progression against expected length of stay and evidence-based clinical criteria.
  16. Identify and escalate barriers that may impact payer approval, patient status, authorization, or reimbursement.
  17. Collaborate with Case Management to ensure alignment between payer requirements and discharge readiness without assuming discharge planning responsibilities.
  18. Participate in denial trend analysis, quality initiatives, and process improvement efforts.
  19. Support audit activities, including RAC, governmental, and commercial payer audits, and participate in pre-bill review processes as needed.
Qualifications
  • Education & Training:
    • Associate's degree in nursing required.
    • Bachelor's degree in nursing preferred.
  • Experience:
    • 3+ years of acute care experience required.
    • Experience in utilization review or case management preferred.
  • Licensure/Certification/Registration:
    • Current RN license in the state of Texas required
    • BLS required
    • Must possess and maintain a valid driver's license as employees may occasionally be required to operate a company vehicle. Reasonable accommodations may be provided as required by law.
  • Key Skills:
    • Comprehensive knowledge of CMS regulations, utilization management standards, and commercial payer requirements.
    • Strong communication, collaboration, critical thinking, and analytical skills.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable law.

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