Mid Level Utilization Management Specialist Jobs
Mid level utilization management specialist jobs go to clinicians and analysts ready to own case review workflows, apply independent clinical judgment, and guide teams through complex authorization decisions without constant oversight. Hiring runs across Healthcare & Medical Services, Insurance, and Manufacturing, with a strong mix of remote and on-site positions, and employers like UF Health, Memorial Healthcare System, and Optum competing for utilization management specialists at this level now.
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Showing 4 of 17+ Mid Level Utilization Management Specialist jobs
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 Specialist Jobs: Frequently Asked Questions
How do I get a mid level utilization management specialist job?
Position your experience around independent clinical decision-making, not just task completion. Highlight specific authorization workflows you have owned, criteria sets you have applied such as InterQual or Milliman, and any measurable outcomes you have driven, like denial reduction or turnaround improvement. Tailoring your resume to reflect scope of ownership, rather than a list of duties, is what separates mid level candidates from early-career applicants in this field.
Which companies hire mid level utilization management specialists?
Companies hiring mid level utilization management specialists right now include UF Health, Memorial Healthcare System, and Optum, based on current listings on Migrate Mate as of September 2026. Health insurers, managed care organizations, and large hospital systems drive the most consistent hiring at this level, often seeking candidates who can work across multiple lines of business or care settings with limited supervision.
Are there remote mid level utilization management specialist jobs?
Yes, and the share is substantial for this role. About 60% of mid level utilization management specialist openings are remote or hybrid as of September 2026, reflecting how much of this work, including chart reviews, authorization determinations, and payer communication, can be performed entirely outside a clinical facility. Fully remote roles typically require reliable internet access and familiarity with care management platforms.
How do I move up to a mid level utilization management specialist role?
Getting to mid level means building depth in clinical criteria application, showing you can manage a caseload independently, and producing outcomes your team can point to. Over your first few years, seek exposure to different care settings, learn multiple utilization review criteria systems, and take ownership of quality or audit projects. Demonstrating that you flag issues proactively and influence decisions, rather than just executing instructions, is what earns mid level consideration.
Which industries hire the most mid level utilization management specialists?
Mid Level utilization management specialist 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 utilization management sits at the intersection of clinical care and cost containment, functions that health plans, managed care firms, and integrated delivery networks all need to staff with experienced, decision-ready clinicians rather than entry-level reviewers.