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Registered Nurse - Utilization Management

  • Texas, Austin

  • 08/27/2026

  • Contract

  • Active

Job Description:

  • Job Summary
    The Registered Nurse – Utilization Management is responsible for reviewing patient care plans, medical necessity, and resource utilization to ensure appropriate, cost-effective, and quality care delivery. This role collaborates with physicians, case managers, and insurance providers to support patient outcomes while maintaining compliance with regulatory and organizational standards.

    Key Responsibilities
    1. Review medical necessity for inpatient and outpatient services.
    2. Conduct utilization reviews to ensure compliance with payer requirements and organizational policies.
    3. Collaborate with physicians, case managers, and insurance providers to coordinate care.
    4. Document reviews and maintain accurate patient records.
    5. Identify opportunities for cost-effective care without compromising quality.
    6. Support discharge planning and transitions of care.
    7. Ensure compliance with regulatory, accreditation, and organizational standards.
    8. Participate in quality improvement initiatives related to utilization management.

    Required Qualifications
    1. Current Registered Nurse (RN) license.
    2. Associate’s or Bachelor’s degree in Nursing (BSN preferred).
    3. Minimum of 2–3 years of clinical nursing experience.
    4. Strong knowledge of medical necessity criteria, utilization review processes, and payer requirements.
    5. Excellent communication, analytical, and problem-solving skills.
    6. Ability to work collaboratively across interdisciplinary teams.

    Preferred Qualifications
    1. Prior experience in utilization management, case management, or insurance review.
    2. Certification in Utilization Review or Case Management (e.g., CCM, CPUM).
    3. Familiarity with electronic health record (EHR) systems.

    Certifications
    1. RN license – required.
    2. BLS certification – required.
    3. CCM or CPUM certification – preferred.

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