Utilization Management Specialist Jobs
Utilization Management Specialist jobs are open across health insurance, managed care, hospital systems, and behavioral health organizations, at levels from entry-level reviewer to senior and lead, with specializations in medical necessity review, prior authorization, and case coordination. 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 Specialist Jobs by Experience Level
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Find JobsUtilization Management Specialist 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 specialist jobs.
- Active RN, LPN, or clinical licensure required by most employers
- Experience applying InterQual or Milliman medical necessity criteria
- Prior authorization or utilization review experience in a managed care setting
- Proficiency with electronic health records and payer-specific care management platforms
- Knowledge of Medicare, Medicaid, and commercial insurance coverage guidelines
- Certified Case Manager (CCM) or equivalent credential preferred or required
Tips for Your Utilization Management Specialist Job Search
Tailor your resume to criteria language
Hiring managers in utilization management screen for terms like 'medical necessity criteria,' 'InterQual,' and 'Milliman.' Pull the exact language from each job posting and mirror it in your resume's work history and skills sections.
Highlight your clinical background strategically
If you hold an RN, LPN, or other clinical license, list it prominently near your name. Many UM roles require active licensure, and recruiters filter on this before reading anything else on your application.
Target payers, not just providers
Health insurance companies and managed care organizations post far more utilization management specialist openings than hospitals do. Broaden your search beyond hospital careers pages and focus on payer career portals and managed care networks.
Apply early to roles that fit
Migrate Mate lists utilization management specialist openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Prepare for criteria-based scenario questions
Interviewers typically present a clinical vignette and ask how you would apply medical necessity criteria to approve or deny a service. Practice walking through a case using InterQual or Milliman logic out loud before your interview.
Negotiate using your certification status
A CCM or ACM credential, or documented experience with a major criteria set, gives you a concrete negotiating point during offer conversations. Reference it specifically when discussing compensation rather than making a general experience argument.
Utilization Management Specialist Jobs: Frequently Asked Questions
Which companies are hiring the most utilization management specialists?
The companies hiring the most utilization management specialists 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. Health insurers and managed care organizations consistently account for the largest volume of postings.
How many utilization management specialist jobs are remote?
About 76% of utilization management specialist openings are fully remote or hybrid as of November 2026, making it one of the more remote-friendly clinical roles available. Prior authorization and medical necessity review functions tend to be the most commonly offered as fully remote positions, while concurrent review roles that require facility coordination are more often on-site or hybrid.
How do you become a utilization management specialist?
Most utilization management specialists start by earning an active clinical license, most commonly as a registered nurse, then gaining direct patient care experience in a hospital, home health, or managed care setting. From there, you build familiarity with medical necessity criteria sets like InterQual or Milliman, either on the job or through self-study. Pursuing a certification such as the Certified Case Manager credential strengthens your candidacy for senior roles.
Can I get a utilization management specialist job with limited experience?
Yes, some entry-level utilization review positions are open to candidates with a clinical license and limited direct UM experience, particularly at regional health plans and third-party administrators. Emphasize any exposure to care coordination, discharge planning, or insurance authorization in your current or previous role. Completing a criteria-set training course before applying, and noting it on your resume, can close the gap when your UM-specific background is thin.
What does the utilization management specialist interview process look like?
Most utilization management interviews include a phone screen with HR or a recruiter, followed by one or two structured interviews with a UM director or clinical supervisor. Expect at least one clinical scenario question where you walk through how you would apply medical necessity criteria to a case. Some employers also include a short written or verbal exercise involving a sample authorization request, particularly for roles that handle complex medical or behavioral health cases.
Where can I find and apply to utilization management specialist jobs?
You can find and apply to utilization management specialist jobs on Migrate Mate, which lists current openings from employers across the United States in one place. Find the roles that match your clinical background and target setting, then apply directly to each listing that fits.
See All 181+ Utilization Management Specialist Jobs
Find roles that match your experience and apply in just a few clicks.
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