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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INTRODUCTION
We are seeking an experienced Care Management Coordinator to join our Infusion Therapy team. This role is responsible for performing utilization management reviews to determine the medical necessity of requested healthcare services, ensuring members receive appropriate, evidence-based care while maintaining compliance with regulatory and accreditation standards. This position is ideal for a clinically strong RN who thrives in a collaborative environment, enjoys critical thinking, and is passionate about improving patient outcomes through high-quality utilization management.
ROLE AND RESPONSIBILITIES
- Conduct medical necessity reviews for infusion therapy services using InterQual, medical policies, and evidence-based clinical guidelines.
- Review medical records, treatment plans, and clinical documentation to authorize medically necessary services.
- Collaborate with physicians and providers to obtain additional clinical information and clarify treatment plans when needed.
- Present cases that do not meet medical necessity criteria to the Medical Director for final determination.
- Identify discharge planning needs and collaborate with case management to support appropriate transitions of care.
- Ensure authorization decisions comply with federal, state, and accreditation requirements while meeting established turnaround times.
- Identify utilization trends, quality concerns, and opportunities for process improvement.
- Accurately document all clinical reviews and maintain the integrity of care management systems.
- Serve as a clinical resource and advocate for members navigating the healthcare system.
BASIC QUALIFICATIONS
- Active Pennsylvania Registered Nurse (RN) license required.
- Previous experience in Utilization Management, Care Management, Case Management, or Prior Authorization.
- Strong understanding of medical necessity review, healthcare regulations, and evidence-based clinical criteria.
- Experience utilizing InterQual or similar medical necessity guidelines strongly preferred.
- Excellent critical thinking, clinical assessment, communication, and documentation skills.
- Ability to independently prioritize a high-volume workload while meeting regulatory turnaround times.
PREFERRED QUALIFICATIONS
- Infusion therapy, specialty pharmacy, oncology, or complex care management.
- Managed care, health plan, or payer experience.
- Experience reviewing inpatient, outpatient, or specialty service authorizations.
This is an excellent opportunity for an experienced RN who enjoys combining clinical expertise with analytical decision-making to ensure members receive timely, appropriate, and high-quality care while supporting organizational quality and compliance initiatives.
INTRODUCTION
We are seeking an experienced Care Management Coordinator to join our Infusion Therapy team. This role is responsible for performing utilization management reviews to determine the medical necessity of requested healthcare services, ensuring members receive appropriate, evidence-based care while maintaining compliance with regulatory and accreditation standards. This position is ideal for a clinically strong RN who thrives in a collaborative environment, enjoys critical thinking, and is passionate about improving patient outcomes through high-quality utilization management.
ROLE AND RESPONSIBILITIES
- Conduct medical necessity reviews for infusion therapy services using InterQual, medical policies, and evidence-based clinical guidelines.
- Review medical records, treatment plans, and clinical documentation to authorize medically necessary services.
- Collaborate with physicians and providers to obtain additional clinical information and clarify treatment plans when needed.
- Present cases that do not meet medical necessity criteria to the Medical Director for final determination.
- Identify discharge planning needs and collaborate with case management to support appropriate transitions of care.
- Ensure authorization decisions comply with federal, state, and accreditation requirements while meeting established turnaround times.
- Identify utilization trends, quality concerns, and opportunities for process improvement.
- Accurately document all clinical reviews and maintain the integrity of care management systems.
- Serve as a clinical resource and advocate for members navigating the healthcare system.
BASIC QUALIFICATIONS
- Active Pennsylvania Registered Nurse (RN) license required.
- Previous experience in Utilization Management, Care Management, Case Management, or Prior Authorization.
- Strong understanding of medical necessity review, healthcare regulations, and evidence-based clinical criteria.
- Experience utilizing InterQual or similar medical necessity guidelines strongly preferred.
- Excellent critical thinking, clinical assessment, communication, and documentation skills.
- Ability to independently prioritize a high-volume workload while meeting regulatory turnaround times.
PREFERRED QUALIFICATIONS
- Infusion therapy, specialty pharmacy, oncology, or complex care management.
- Managed care, health plan, or payer experience.
- Experience reviewing inpatient, outpatient, or specialty service authorizations.
This is an excellent opportunity for an experienced RN who enjoys combining clinical expertise with analytical decision-making to ensure members receive timely, appropriate, and high-quality care while supporting organizational quality and compliance initiatives.
Utilization Management Specialist Jobs by Experience Level
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Find JobsUtilization Management Specialist Job Market
Who's Hiring
- Humana19
- CVS Health16
- CommunityCare5
- Nascentia Health5
- Blue Shield of California5
Top Industries Hiring
- Healthcare & Medical Services33
- Insurance15
- Technology & Software3
- Education1
- 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 Humana, CVS Health, and CommunityCare, with the largest share of openings in California, New York, and Michigan, based on current listings on Migrate Mate as of August 2026. Health insurers and managed care organizations consistently account for the largest volume of postings.
How many utilization management specialist jobs are remote?
About 77% of utilization management specialist openings are fully remote or hybrid as of August 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.
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