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How much do utilization review rn jobs pay per hour?

As of Aug 1, 2026, the average hourly pay for utilization review rn in Springfield, MA is $41.15, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.26 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 Springfield, MA? The most popular types of Utilization Review Rn jobs in Springfield, MA are:
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What cities near Springfield, MA are hiring for Utilization Review Rn jobs? Cities near Springfield, MA with the most Utilization Review Rn job openings:
Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Springfield, MA as of July 2026, with employment types broken down into 1% As Needed, 79% Full Time, 16% Part Time, 2% Temporary, and 2% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution, with an average salary of $85,596 per year, or $41.2 per hour.

Center for Care Coordination-Team Lead Utilization Review Nurse- Full Time

Connecticut Children's

Hartford, CT • On-site

Full-time

Posted 5 days ago

Connecticut Children's Medical Center rating

7.7

Company rating: 7.7 out of 10

Based on 45 frontline employees who took The Breakroom Quiz

219th of 1,054 rated hospitals

Job description


The Team Lead for Utilization Review (UR) is responsible for the day-to-day activities and oversight of the UR Nurses, under the guidance and support of the Manager of Case Management and Director of the Center. Provides leadership and direction around scheduling, supervision and daily operations, while looking strategically at how workflow and process improvement can optimize and improve the role of Case Management and patient/family care through the institution. Lead will identify challenges and systems issues that need to be elevated to the Manager and Center Leadership.
Responsibilities
Team Lead-20%:
  • Daily clinical support and supervision of UR nurses.
  • Scheduling for UR coverage.
  • UR Policies and Procedure review and maintenance.
  • Onboarding and support of new staff.
  • Individual and team supervision / support following challenging cases.
  • Work with Manager to establish and track metrics, data and initiatives that improve process
  • UR Team Communications.
  • Assists Manager in completing performance evaluations.
  • Provides formal and informal support of members through engagement activities, team supervision and staff meetings.
  • Develop and maintain effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. -20%
  • Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews for Medicaid beneficiaries, as well as other insurers and self-pay patients, based on appropriate guidelines. Uses these criteria to screen for appropriateness of level of care based on medical record documentation. -9%
  • Gathers clinical information to conduct continued stay utilization review activities with payers pursuant to department policies and procedures and the Utilization Review Plan. -5%
  • Escalates cases as appropriate for secondary review. -5%
  • Performs concurrent and retrospective clinical reviews utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines. -5%
  • Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -9%
  • Identifies and consistently documents information on any progression of care or patient flow barriers using the designated electronic tool used to track avoidable days/delays. -2.5%
  • Engages hospital case management and care team colleagues in collaborative problem solving regarding appropriate utilization of resources. -5%
  • Represents Utilization Management at various committees, as needed. -.5%
  • Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. 2

  • Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. -10%
  • Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -5%

  • Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5%
  • Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -1.0%
  • Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.5%
  • Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children's patients.
  • Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources
  • Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system. -5%
  • Performs other job-related duties as assigned 0

Qualifications
Education and/or Experience Required:
  • Education: Bachelor of Science in Nursing (BSN)
  • Experience: 3 years' nursing in a healthcare setting

Education and/or Experience Preferred:
  • Experience:
    • Pediatric nursing experience
    • Previous experience in Utilization Review
    • Previous experience in Case Management or Discharge planning

License and/or Certification Required:
  • State of Connecticut Nursing License

License and/or Certification Preferred:
  • Case Management Certification.

Knowledge, Skills and Abilities:
Knowledge:
  • Demonstrate working knowledge of how to interpret and apply medical care criteria.
  • Knowledge of community resources, treatment options, home health availability, funding options and special programs.
  • UR Team Lead has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. Lead maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements.

Skills:
  • Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards
  • Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
  • Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC.
  • Strong working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines® and be proficient in medical record reviews.
  • UR Lead will support process improvement activities and report key metrics to facility leadership as requested.
  • The UR Lead will demonstrate an ability to effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment.
  • Lead will provide support to the hospital's UM Committee as needed and collaborate with multiple leaders at various levels throughout the organization.

Abilities:
  • Self-directed/motivated, organized, diplomatic and team-oriented.
  • Function in a high energy, fast moving environment.
  • Maintain flexibility as determined by acuity of medical unit.
  • Prioritize case load.
  • Collaborate with various disciplines
  • Communicate effectively and efficiently
  • Prioritize and manage multiple tasks.
  • Excellent written and verbal communication skills.

About Us
Connecticut Children's is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children's offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.
At Connecticut Children's, treating children isn't just our job - it's our passion. As a leading children's health system experiencing steady growth, we're excited to expand our team with exceptional team members who share our vision of transforming children's health and well-being as one team.

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