Mid Level Utilization Management Nurse Jobs
Mid level utilization management nurse jobs go to nurses ready to own case review workflows, guide less experienced peers, and make coverage determinations with minimal oversight. Openings run across Healthcare & Medical Services, Insurance, and Manufacturing, with 60% remote or hybrid availability and employers like UF Health, Memorial Healthcare System, and Optum hiring at this level now.
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Position Summary:
Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.
Essential Functions and Responsibilities as Assigned:
1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
3. Works collaboratively with ICM service lines to expedite patient discharge.
4. Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement.
5. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc.
6. Facilitates peer to peer reviews with payer/providers.
7. Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers,
8. Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures.
9. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
10. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
11. Assists with orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
12. Performs other related duties as required and directed.
Qualifications:
Required
- State licensure as a registered nurse (RN)
- Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
- Three years of recent nursing or utilization management experience with an acute care hospital
Preferred:
- Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management.
- Certification in Case Management Certification (ACM or CCM)
- Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN)
- Schedule: Full-time
- Requisition ID: 26010547
- Daily Work Times: 8:00am-4:00pm
- Hours Per Pay Period: 80
- On Call: No
- Weekends: Yes
About Us
McLaren Health Care, headquartered in Grand Blanc, Michigan, is a $7.3 billion, fully integrated health care delivery system committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals in Michigan, ambulatory surgery centers, imaging centers, a 640-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 732,838 lives in Michigan and Indiana, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer centers. McLaren has 20,000 full-, part-time and contracted employees and more than 113,000 network providers throughout Michigan, Indiana and Ohio.
Position Summary:
Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.
Essential Functions and Responsibilities as Assigned:
1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
3. Works collaboratively with ICM service lines to expedite patient discharge.
4. Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement.
5. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc.
6. Facilitates peer to peer reviews with payer/providers.
7. Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers,
8. Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures.
9. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
10. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
11. Assists with orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
12. Performs other related duties as required and directed.
Qualifications:
Required
- State licensure as a registered nurse (RN)
- Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
- Three years of recent nursing or utilization management experience with an acute care hospital
Preferred:
- Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management.
- Certification in Case Management Certification (ACM or CCM)
- Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN)
- Schedule: Full-time
- Requisition ID: 26010547
- Daily Work Times: 8:00am-4:00pm
- Hours Per Pay Period: 80
- On Call: No
- Weekends: Yes
About Us
McLaren Health Care, headquartered in Grand Blanc, Michigan, is a $7.3 billion, fully integrated health care delivery system committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals in Michigan, ambulatory surgery centers, imaging centers, a 640-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 732,838 lives in Michigan and Indiana, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer centers. McLaren has 20,000 full-, part-time and contracted employees and more than 113,000 network providers throughout Michigan, Indiana and Ohio.
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Mid Level Utilization Management Nurse Jobs: Frequently Asked Questions
How do I get a mid level utilization management nurse job?
Position yourself around clinical decision-making and independent case management. Highlight experience conducting prior authorization reviews, applying InterQual or Milliman criteria, and coordinating with multidisciplinary teams. Emphasize situations where you owned a caseload or process without heavy supervision. Certifications like the Certified Case Manager credential strengthen applications, and demonstrating measurable outcomes from your reviews will set you apart from candidates who list only duties.
Which companies hire mid level utilization management nurses?
Companies hiring mid level utilization management nurses right now include UF Health, Memorial Healthcare System, and Optum, based on current listings on Migrate Mate as of September 2026. Hiring at this level is concentrated among managed care organizations, health insurance plans, and large hospital systems building out their care management and cost-containment functions.
Are there remote mid level utilization management nurse jobs?
Yes, and utilization management is one of the more remote-accessible nursing specialties given its chart-based and telephonic nature. About 60% of mid level utilization management nurse openings are remote or hybrid as of September 2026, making it a strong option for nurses seeking flexibility without stepping away from clinical decision-making work.
How do I move up to a mid level utilization management nurse role?
The path into mid level typically runs through bedside or case management experience where you build comfort reading clinical documentation and applying medical necessity criteria. Over time, taking on more complex cases, seeking exposure to payer-side reviews, and earning a certification in case management or utilization review signals readiness. Demonstrating ownership of outcomes rather than just completing tasks is what separates mid level candidates from entry-level applicants.
Which industries hire the most mid level utilization management nurses?
Mid Level utilization management nurse roles concentrate in Healthcare & Medical Services, Insurance, and Manufacturing, based on current listings on Migrate Mate as of September 2026. These sectors drive demand because they carry the greatest need for clinical review functions that control costs, meet regulatory requirements, and ensure appropriate levels of care across large member or patient populations.