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Utilization Review Rn Jobs in Richmond, VA (NOW HIRING)

Humana

Compliance UM Nurse (Wed - Sun)

Richmond, VA · On-site

Become a part of our caring community The Compliance Nurse 2 reviews utilization management ... Licensed Registered Nurse (RN) in a compact state with no disciplinary action.?? * Must have?valid ...

Syra Health

ACT Registered Nurse

Petersburg, VA · On-site

Audit physician orders for medication changes, lab work, informed consents, and AIMS utilization ... Participate in daily staff organizational meetings, treatment planning reviews, and shift ...

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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 14, 2026, the average hourly pay for utilization review rn in Richmond, VA is $41.94, according to ZipRecruiter salary data. Most workers in this role earn between $33.12 and $48.17 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.

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 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 knowledge of medical coding and insurance processes can enhance your qualifications. Gaining experience in case management or health insurance companies can also improve your chances of entering the field.

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.

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 Richmond, VA?

The most popular types of Utilization Review Rn jobs in Richmond, VA are:

What are popular job titles related to Utilization Review Rn jobs in Richmond, VA?

For Utilization Review Rn jobs in Richmond, VA, the most frequently searched job titles are:

What job categories do people searching Utilization Review Rn jobs in Richmond, VA look for?

The top searched job categories for Utilization Review Rn jobs in Richmond, VA are:

What cities near Richmond, VA are hiring for Utilization Review Rn jobs?

Cities near Richmond, VA with the most Utilization Review Rn job openings:

Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Richmond, VA as of August 2026, with employment types broken down into 5% As Needed, 70% Full Time, 21% Part Time, and 4% Contract. Highlights an 94% In-person, 2% Hybrid, and 4% Remote job distribution, with an average salary of $87,231 per year, or $41.9 per hour.

Clinical Authorization Specialist (Utilization Review)

Hallmark Youthcare Richmond, Inc.

Henrico, VA • On-site

Other

Medical, Retirement

Posted 11 days ago

Job description

As a leading Residential Treatment Center in the Greater Richmond area, Hallmark Youthcare treats adolescents with emotional and behavioral challenges triggered by trauma. Treatment is provided in a warm and friendly environment by a group of well-trained, highly motivated staff that take pride in delivering quality care in a fast-paced environment.
We are seeking a detail-oriented Clinical Authorization Specialist (Utilization Review) to join our healthcare team. The ideal candidate will have experience in prior authorizations, insurance verification, utilization review, and medical necessity determinations. This role is responsible for ensuring that medical services are appropriately authorized, clinically supported, and compliant with payer guidelines before, during, and after patient care.
The Clinical Authorization Specialist serves as a liaison between healthcare providers, insurance companies, and patients to facilitate timely approvals while minimizing denials and delays in care.
In addition, this role maintains communication with referral sources (CSA/FAPT/IACCT) to coordinate placement and reimbursement standards for transfers from emergency placements and document submission to Magellan for Medicaid consideration.
Key Responsibilities

  • Master's degree in health services field.
  • Review and process prior authorization requests for medical procedures, diagnostic testing, medications, therapies, and specialty services.
  • Evaluate clinical documentation to determine medical necessity using payer guidelines, evidence-based criteria, and insurance policies.
  • Perform prospective, concurrent, and retrospective utilization reviews.
  • Communicate with physicians, nurses, case managers, and insurance representatives to obtain required clinical documentation.
  • Submit authorization requests and monitor status through payer portals and electronic health record (EHR/EMR) systems.
  • Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
  • Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
  • Maintain accurate records of all authorization activities, communications, and determinations.
  • Stay current on payer policies, CMS regulations, and utilization management best practices.
  • Assist with appeals and peer-to-peer review coordination when necessary.
  • Meet productivity, turnaround time, quality, and compliance standards.
Required Qualifications
  • High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
  • Minimum of 2 years of experience in prior authorization, utilization review, medical insurance, case management, including admissions.
  • Strong understanding of commercial insurance, Medicare, Medicaid, and managed care plans.
  • Experience working with electronic medical records (EMR/EHR) and payer authorization portals.
  • Excellent organizational, analytical, and problem-solving skills.
  • Strong verbal and written communication abilities.
  • Ability to prioritize multiple tasks in a fast-paced healthcare environment.

Benefits:
Set schedule Monday- Friday 9 am- 5pm
Full benefit package available
Matching 401K
Time off accrued each payroll
Free employee meals

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