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Utilization Review Rn Jobs in Houston, TX (NOW HIRING)

UHS

Utilization Management Coordinator

Houston, TX · On-site

Completes admission and continued stay reviews with managed care companies and obtains ... Preferred: TX LVN, RN or LCDC license. * Experience Required: Minimum of one year of case ...

UHS

Utilization Management Coordinator

Houston, TX · On-site

Completes admission and continued stay reviews with managed care companies and obtains ... Preferred: TX LVN, RN or LCDC license. * Experience Required: Minimum of one year of case ...

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Utilization Review Rn information

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How much do utilization review rn jobs pay per hour?

As of Jun 21, 2026, the average hourly pay for utilization review rn in Houston, TX is $40.36, according to ZipRecruiter salary data. Most workers in this role earn between $31.88 and $46.35 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.
What are the most commonly searched types of Utilization Review Rn jobs in Houston, TX? The most popular types of Utilization Review Rn jobs in Houston, TX are:
What are popular job titles related to Utilization Review Rn jobs in Houston, TX? For Utilization Review Rn jobs in Houston, TX, the most frequently searched job titles are:
What job categories do people searching Utilization Review Rn jobs in Houston, TX look for? The top searched job categories for Utilization Review Rn jobs in Houston, TX are:
What cities near Houston, TX are hiring for Utilization Review Rn jobs? Cities near Houston, TX with the most Utilization Review Rn job openings:
Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Houston, TX as of June 2026, with employment types broken down into 86% Full Time, and 14% Part Time. Highlights an 57% In-person, and 43% Remote job distribution, with an average salary of $83,947 per year, or $40.4 per hour.
Utilization Review RN

Utilization Review RN

Houston Methodist Cypress Hospital

Cypress, TX • On-site

Full-time

Posted 13 days ago

Houston Methodist rating

8.1

Company rating: 8.1 out of 10

Based on 293 frontline employees who took The Breakroom Quiz

69th of 874 rated healthcare providers

Job description

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management.
FLSA STATUS
Exempt
QUALIFICATIONS
EDUCATION
  • Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
  • Bachelor’s degree preferred

EXPERIENCE
  • Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required
  • RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

SKILLS AND ABILITIES
  • Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
  • Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
  • Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
  • Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations
  • Recent work experience in a hospital or insurance company providing utilization review services
  • Knowledge of Medicare, Medicaid, and Managed Care requirements
  • Progressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
  • Progressive knowledge of utilization management, case management, performance improvement, and managed care reimbursement
  • Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
  • Strong assessment, organizational, and problem-solving skills
  • Maintains level of professional contributions as defined in Career Path program
  • Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)

ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
  • Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers; listens and responds to the ideas of others.
  • Collaborates with the access management team to ensure accurate and complete clinical and payer information. Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
  • Contributes towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS
  • Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources. Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization.
  • Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.
  • Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols.
  • Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review, peer-peer discussions, and payer denial- appeal needs. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

QUALITY/SAFETY ESSENTIAL FUNCTIONS
  • Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care. Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continue stay.
  • Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Identifies areas for improvement based on an understanding of evidence-based practice/performance improvement projects based on these observations.
  • Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of the care process

FINANCE ESSENTIAL FUNCTIONS
  • Contributes to meeting department financial targets, with a focus on appropriate utilization and denial prevention. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.
  • Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care, and program compliance using evidence-based, nationally recognized guidelines. Manages assigned patients and communicates and collaborates with the case manager to assist with appropriate interventions to avoid denial of payment.
  • Collaborates with the revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS
  • Identifies and presents areas for improvement in patient care or department operations and offers solutions by participating in department projects and activities.
  • Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

SUPPLEMENTAL REQUIREMENTS
    WORK ATTIRE
    • Uniform: No
    • Scrubs: No
    • Business professional: Yes
    • Other (department approved): No

    ON-CALL*
    *Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
    • On Call* Yes

    TRAVEL**
    **Travel specifications may vary by department**
    • May require travel within the Houston Metropolitan area Yes
    • May require travel outside Houston Metropolitan area No
QUALIFICATIONS
EDUCATION
  • Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
  • Bachelor’s degree preferred

EXPERIENCE
  • Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required
  • RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

Company Profile:

Houston Methodist Cypress Hospital, Houston Methodist's eighth hospital, opened in the first quarter of 2025 in a prime location in the heart of the rapidly growing U.S. 290 corridor. It incorporates the most advanced technology available, featuring innovations designed to enhance communication between patients, physicians, staff and families. The facility combines state-of-the-art technology with world-class clinicians, creating an unparalleled experience for patients, employees and physicians.

Houston Methodist is an Equal Opportunity Employer.

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