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Utilization Review Rn Jobs in Fort Mill, SC (NOW HIRING)

Acadia Healthcare

Utilization Specialist

Lancaster, SC · On-site

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...

MUSC

Nurse Case Manager

Lancaster, SC · On-site

... or utilization review work experience preferred. Additional Education: Graduate from an accredited school of nursing and a minimum of one year of work experience as a Registered Nurse required.

genex

Telephonic Case Manager (RN)

Columbia, SC

Responsible for the performance of Utilization Review services, including pre-admission ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...

genex

Telephonic Case Manager (RN)

Columbia, SC

Responsible for the performance of Utilization Review services, including pre-admission ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...

Genex

Telephonic Case Manager (RN)

Charlotte, NC · On-site

Currently seeking a Telephonic Nurse Case Manager. Qualified candidate will need to be located ... Responsible for the performance of Utilization Review services, including pre-admission ...

Saber Healthcare Group

Mobile MDS (RN)

Charlotte, NC · On-site

Active, unencumbered Registered Nurse license in the State of practice * Must have two (2) years experience working the RAI/MDS process * Must be able to travel, as necessary Shift & Wage ...

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Utilization Review Rn information

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How much do utilization review rn jobs pay per hour?

As of Aug 26, 2026, the average hourly pay for utilization review rn in Fort Mill, SC is $37.16, according to ZipRecruiter salary data. Most workers in this role earn between $29.38 and $42.69 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.

What are the most commonly searched types of Utilization Review Rn jobs in Fort Mill, SC?

The most popular types of Utilization Review Rn jobs in Fort Mill, SC are:

What are popular job titles related to Utilization Review Rn jobs in Fort Mill, SC?

For Utilization Review Rn jobs in Fort Mill, SC, the most frequently searched job titles are:

What job categories do people searching Utilization Review Rn jobs in Fort Mill, SC look for?

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What cities near Fort Mill, SC are hiring for Utilization Review Rn jobs?

Cities near Fort Mill, SC with the most Utilization Review Rn job openings:

Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Fort Mill, SC as of August 2026, with employment types broken down into 1% As Needed, 79% Full Time, 16% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 2% Hybrid, and 11% Remote job distribution, with an average salary of $77,283 per year, or $37.2 per hour.

Utilization Review RN Appeals Specialist

CaroMont Health

Gastonia, NC • On-site

Full-time

Re-posted 8 days ago

CaroMont Health rating

6.4

Company rating: 6.4 out of 10

Based on 60 frontline employees who took The Breakroom Quiz

644th of 893 rated healthcare providers

Job description

Job Summary:  The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue.  This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner.  In addition, the following are essential duties and responsibilities of the Nurse Reviewer:    Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is warranted.   Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.          Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.   Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.   Discuss documentation-related, level of care decisions, and clinical issues with physicians and other appropriate staff.   Ensure compliance with HIPAA regulations, to include confidentiality, as required.  Other duties as assigned.   Works closely with the Utilization Review Specialists to ensure that concurrent medical necessity is achieved.  Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.

Qualifications:  Bachelor's degree from an accredited college with a strong clinical background, MSN preferred.  Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.   Knowledge in areas such as InterQual Level of Care Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.    Must have excellent oral communication and organizational skills. Must have excellent writing skills. Previous experience with clinical resource utilization analysis, auditing, appeal writing, and chart review. Knowledge of state and federal regulations in regard to Medicare and Quality Management activities is a must.  . Certification is required within one year of hire.

EOE AA M/F/Vet/Disability

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