Utilization Management Nurse Jobs
Utilization Management Nurse jobs are open across health insurance payers, hospital systems, managed care organizations, and third-party administrators, at every level from staff nurse to senior and lead, with specializations in prior authorization, concurrent review, and case management. Find a role that fits from the openings below and apply directly.
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Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment.
Essential Responsibilities:
- Plans, develops, assesses and evaluates care provided to members.
- Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
- Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
- Assesses high risk patients in need of post-hospital care planning.
- Develops and coordinates the implementation of a discharge plan to meet patients identified needs.
- Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
- Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
- Participates in the Bed Huddles and carries out recommendations congruent with the patients needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
- Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities.
- Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
- Refers patients to community resources to meet post hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
- Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
- Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
- Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
- Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities.
- Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
- Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed.
- Participates in committees, teams or other work projects/duties as assigned.
Basic Qualifications:
- Two (2) years combined RN experience in an acute care setting or case management required.
- Completion of an accredited RN training program that allows graduates to take RN license exam.
- Registered Nurse License (California)
- Basic Life Support
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
- Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
- Demonstrated ability in planning, organizing, conflict resolution and negotiating skills.
- Computer literacy skills required.
- Bachelors degree in nursing or healthcare related field.
PrimaryLocation : California,San Diego,Zion Medical Center
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri *Rotating weekends and holidays
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 04:30 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : B21|AFSCME|SCNSC
Job Level : Individual Contributor
Job Category : Nursing Licensed & Nurse Practitioners
Department : ZION MEDICAL CENTER - Utilization Management - 0801
Travel : No
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.
For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:
- Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.
- Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.
- Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.
Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment.
Essential Responsibilities:
- Plans, develops, assesses and evaluates care provided to members.
- Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
- Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
- Assesses high risk patients in need of post-hospital care planning.
- Develops and coordinates the implementation of a discharge plan to meet patients identified needs.
- Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
- Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
- Participates in the Bed Huddles and carries out recommendations congruent with the patients needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
- Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities.
- Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
- Refers patients to community resources to meet post hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
- Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
- Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
- Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
- Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities.
- Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
- Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed.
- Participates in committees, teams or other work projects/duties as assigned.
Basic Qualifications:
- Two (2) years combined RN experience in an acute care setting or case management required.
- Completion of an accredited RN training program that allows graduates to take RN license exam.
- Registered Nurse License (California)
- Basic Life Support
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
- Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
- Demonstrated ability in planning, organizing, conflict resolution and negotiating skills.
- Computer literacy skills required.
- Bachelors degree in nursing or healthcare related field.
PrimaryLocation : California,San Diego,Zion Medical Center
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri *Rotating weekends and holidays
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 04:30 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : B21|AFSCME|SCNSC
Job Level : Individual Contributor
Job Category : Nursing Licensed & Nurse Practitioners
Department : ZION MEDICAL CENTER - Utilization Management - 0801
Travel : No
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.
For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:
- Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente's policies and procedures.
- Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.
- Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.
Utilization Management Nurse Jobs by Experience Level
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Find JobsUtilization Management Nurse Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services11
- Insurance8
- Education2
- Technology & Software2
- Manufacturing1
What Employers Look For
The qualifications that appear most often in utilization management nurse jobs.
- Active registered nurse license in the state of hire or compact licensure
- Minimum two to three years of acute care or direct clinical nursing experience
- Working knowledge of InterQual or Milliman Care Guidelines criteria
- Experience with prior authorization, concurrent review, or discharge planning
- Familiarity with ICD-10 coding and medical necessity documentation standards
- Proficiency with electronic health records and utilization management software platforms
Tips for Your Utilization Management Nurse Job Search
Tailor your resume for UM terminology
Recruiters and applicant tracking systems scan for specific terms like prior authorization, InterQual, MCG criteria, and level-of-care determination. Audit every bullet on your resume and replace vague clinical language with the utilization management vocabulary that appears in the postings you're targeting.
Highlight your criteria knowledge upfront
Many UM nurse postings screen for hands-on experience with InterQual or Milliman Care Guidelines before they read anything else. Put the criteria sets you've worked with, and the volume of cases you've reviewed, near the top of your resume so hiring managers see it immediately.
Filter openings by payer versus provider setting
Health insurance companies, hospital utilization review departments, and independent review organizations each operate differently. Decide which setting fits your background before you apply, because your interview answers will need to reflect that environment's workflows, turnaround time expectations, and regulatory requirements.
Apply early to roles that fit
Migrate Mate lists utilization management nurse openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Prepare for case scenario interview questions
UM nurse interviews almost always include scenario questions where you walk through a denial decision or an appeal. Practice articulating how you apply clinical criteria, document your rationale, and communicate findings to physicians, because interviewers are evaluating your judgment, not just your clinical background.
Negotiate remote status before you accept
Many UM nurse roles are posted as remote-eligible but shift to hybrid after onboarding. Ask directly during the offer stage which days require on-site presence, whether that can change, and what equipment the employer provides, so the arrangement is confirmed in writing before you give notice.
Utilization Management Nurse Jobs: Frequently Asked Questions
Which companies are hiring the most utilization management nurses?
The companies hiring the most utilization management nurses right now include CommunityCare, Kaiser Permanente, and Guidehealth, with the largest share of openings in California, New York, and Florida, based on current listings on Migrate Mate as of November 2026. Payer-side organizations and large hospital systems tend to post the highest volume of openings on an ongoing basis.
How many utilization management nurse jobs are remote?
About 76% of utilization management nurse openings are fully remote or hybrid as of November 2026, making it one of the more remote-accessible nursing specialties. Prior authorization review and telephonic case management roles are the most likely to be fully remote, while concurrent review and discharge planning positions more often require on-site or hybrid presence.
How do you become a utilization management nurse?
Start by earning your registered nurse license and building at least two years of acute care clinical experience in a setting like med-surg, ICU, or emergency. From there, seek out roles in hospital utilization review or case management to gain exposure to criteria-based review. Learning InterQual or Milliman criteria independently accelerates the transition, and earning a certification such as the Certified Case Manager credential strengthens your candidacy for payer-side roles.
Can you get a utilization management nurse job with limited UM experience?
Yes, many employers will consider candidates with strong clinical backgrounds but no formal UM experience, particularly for hospital-based utilization review roles. Emphasize any experience you have with discharge planning, care coordination, or insurance communication. Completing a UM-focused continuing education course, familiarizing yourself with InterQual criteria, and obtaining a case management certification can compensate for a shorter direct UM history.
What does the utilization management nurse interview process look like?
Most UM nurse interviews include an initial phone screen with a recruiter, followed by one or two video or in-person interviews with a nurse manager or clinical operations director. Expect scenario-based questions where you walk through how you would apply clinical criteria to approve or deny a request, handle a physician peer-to-peer, or document a concurrent review decision. Some employers also ask situational questions about turnaround time management and regulatory compliance.
Where can I find and apply to utilization management nurse jobs?
You can find and apply to utilization management nurse jobs on Migrate Mate, which lists current openings from employers across the United States. Search the listings to find roles that match your experience, credentials, and preferred setting, then apply directly to each opening that fits.
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