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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Showing 5 of 233+ Utilization Management Nurse jobs
Hours: Weekend-days, Saturday & Sunday, 7am-3:30pm
At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.
Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few:
- Expect paid time off, parental leave, 401K matching and an employee recognition program.
- Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
- Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.
With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.
And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.
Find a fulfilling career and make a difference with UnityPoint Health.
Responsibilities:- Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.
- Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
- Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
- Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
- Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management.
- Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection.
- Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator.
- Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed.
- Pursues denials at the affiliate level in a timely manner to secure payment of services.
- Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management
- Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems.
- Maintains current knowledge of the UPH Utilization Management Plan.
- Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
- Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed.
- Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements – as needed.
- Required: Associates Degree or Diploma (RN) in Nursing
- Preferred: Bachelor’s Degree or higher preferred in nursing, business, or related field
- Required: 2 years of nursing experience
- Preferred: 5+ years of nursing experience
- Preferred: Experience in Utilization Management, case management, denials, or managed care
- Preferred: Management experience a plus
- Required: Registered Nurse – Licensed and registered in the appropriate state(s)
- Valid driver’s license when driving any vehicle for work-related reasons
Hours: Weekend-days, Saturday & Sunday, 7am-3:30pm
At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.
Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few:
- Expect paid time off, parental leave, 401K matching and an employee recognition program.
- Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
- Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.
With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.
And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.
Find a fulfilling career and make a difference with UnityPoint Health.
Responsibilities:- Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.
- Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
- Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
- Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
- Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management.
- Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection.
- Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator.
- Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed.
- Pursues denials at the affiliate level in a timely manner to secure payment of services.
- Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management
- Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems.
- Maintains current knowledge of the UPH Utilization Management Plan.
- Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
- Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed.
- Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements – as needed.
- Required: Associates Degree or Diploma (RN) in Nursing
- Preferred: Bachelor’s Degree or higher preferred in nursing, business, or related field
- Required: 2 years of nursing experience
- Preferred: 5+ years of nursing experience
- Preferred: Experience in Utilization Management, case management, denials, or managed care
- Preferred: Management experience a plus
- Required: Registered Nurse – Licensed and registered in the appropriate state(s)
- Valid driver’s license when driving any vehicle for work-related reasons
Utilization Management Nurse Jobs by Experience Level
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Find JobsUtilization Management Nurse Job Market
Who's Hiring
- CVS Health25
- Humana13
- CommunityCare6
- Nascentia Health5
- Blue Shield of California5
Top Industries Hiring
- Healthcare & Medical Services33
- Insurance23
- Technology & Software3
- Education1
- 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 CVS Health, Humana, and CommunityCare, with the largest share of openings in California, New York, and Florida, based on current listings on Migrate Mate as of August 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 79% of utilization management nurse openings are fully remote or hybrid as of August 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.
See All 233+ Utilization Management Nurse Jobs
Find roles that match your experience and apply in just a few clicks.
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