Utilization Management experience jobs Skill: Utilization Management experience RN Utilization Management Reviewer
Sagility · Remote, US· Remote · Full-time
RN Utilization Management Reviewer
Sagility · Remote, US· Remote · Full-time · Associate
RN Utilization Management Reviewer
Sagility · Remote, US· Remote · Full-time
Behavioral Health Medical Director - UM Optimization
Centene Corporation · Remote, US· Remote · Full-time · Senior
Utilization Specialist
Acadia Healthcare · Hudson, US
Lead Utilization Review Coordinator
Acadia Healthcare · Chandler, US
Medicare Advantage Utilization Management Physician
SCAN Health Insurance · Long Beach, US· Hybrid · Part-time
Utilization Management Nurse Specialist RN II (ALD)
L.A. Care Health Plan · Los Angeles, US· Hybrid · Full-time · Senior
PRN Utilization Specialist
Oasis Behavioral Health · Knoxville, US
Physician Advisor
Tenet Healthcare Corporation · USFull-time
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Sagility · Posted Jul 23, 2025
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Responsible for day‑to‑day clinical and service authorization review for medical necessity and decision‑making in utilization management.
Salary: $35.00 - $40.00 Hourly pending experience
Conduct timely clinical decision review for services requiring prior authorization Apply established criteria and clinical expertise to determine medical necessity Communicate results verbally, in the medical record, and through official written notification Provide decision‑making guidance to clinical teams Facilitate escalated reviews in accordance with SOPs RN - Associate’s Degree required, Bachelor’s Degree preferred RN, current license issued by the Massachusetts Board of Registration in Nursing CCM (Certified Case Manager) a plus Nice to have: Home Health Care experience Nice to have: Medicare Advantage health Plan experience Medical Dental Vision Life Insurance Short‑Term and Long‑Term Disability Sagility · Posted Jul 23, 2025
Responsible for day‑to‑day clinical and service authorization review for medical necessity and decision‑making in utilization management.
Salary: $35.00 - $40.00 Hourly pending experience.
Conducts timely clinical decision review for services requiring prior authorization Applies established criteria and clinical expertise to determine medical necessity Communicates results verbally, in the medical record, and through official written notification Provides decision‑making guidance to clinical teams on service planning Works closely with clinicians, medical staff and peer reviewers to facilitate escalated reviews RN – Associate’s Degree required, Bachelor’s Degree preferred Nice to have: Home Health Care experience Nice to have: Medicare Advantage health plan experience Sagility · Posted Jul 23, 2025
Responsible for day‑to‑day clinical and service authorization review for medical necessity and decision‑making in utilization management.
Salary: $35.00 - $40.00 Hourly pending experience
Conducts timely clinical decision review for services requiring prior authorization Applies established criteria to determine medical necessity Communicates results of reviews verbally, in the medical record, and through official written notification Provides decision‑making guidance to clinical teams Works closely with clinicians, medical staff and peer reviewers RN – Associate’s Degree required Bachelor’s Degree preferred Nice to have: Home Health Care experience Nice to have: Medicare Advantage health plan experience Centene Corporation · Posted Nov 6, 2026
Provide medical leadership for Utilization Management and cost containment, directing quality improvement and credentialing functions for the business unit.
Pay Range: $215,000.00 - $408,500.00 per year
Assist the Chief Medical Officer to direct and coordinate medical management, quality improvement and credentialing functions Provide medical leadership for utilization management, cost containment, and medical quality improvement activities Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services Support implementation of performance improvement initiatives for capitated providers Assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care Medical Doctor or Doctor of Osteopathy Nice to have: Payer/Managed Care experience Nice to have: Experience treating or managing care for a culturally diverse population Nice to have: Course work in Health Administration, Health Financing, Insurance, or Personnel Management Acadia Healthcare · Posted Nov 6, 2026
Monitor utilization of services for patients to optimize reimbursement for the facility.
Act as liaison between managed care organizations and the facility professional clinical staff Conduct reviews of insurance plans or other managed care organizations and coordinate communication concerning reimbursement requirements Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges and quality of services Conduct quality reviews for medical necessity and services provided High school diploma or equivalent Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field Nice to have: LPN Nice to have: RN Nice to have: LMSW Acadia Healthcare · Posted Nov 5, 2026
Lead Utilization Review Coordinator
Act as liaison between managed care organizations and the facility professional clinical staff Conduct reviews of insurance plans or other managed care organizations and coordinate communication concerning reimbursement requirements Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges and quality of services Conduct quality reviews for medical necessity and services provided Master’s degree in Social Work, Behavioral or Mental Health, or a related health field Nice to have: LMSW Nice to have: LCSW Nice to have: LPC Nice to have: LAC SCAN Health Insurance · Posted Nov 5, 2026
Physician-level decision maker for Medicare Advantage utilization management, reviewing prior authorizations, concurrent and retrospective reviews, and appeals.
Base salary range: $150.00 to $200.00 per hour
Perform physician-level medical necessity review of prior authorization requests, concurrent (inpatient) reviews, and retrospective reviews Render timely determinations consistent with Medicare guidelines and state/federal requirements Conduct peer-to-peer discussions with treating providers Serve as physician reviewer for first-level appeals and refer cases to independent or specialty peer review Maintain availability for urgent/expedited reviews Graduate of an accredited medical school Nice to have: Board certification in Internal Medicine, Family Medicine, or Emergency Medicine Nice to have: Medical Director or Associate Medical Director experience Nice to have: Subspecialty training Nice to have: Appeals and grievances experience L.A. Care Health Plan · Posted Nov 4, 2026
The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status.
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations. Generates approval, modification and denial communications, including member and provider notification. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review. Associate's Degree in Nursing Bachelor's Degree in Nursing Nice to have: Managed Care experience Nice to have: Managed Medi-Cal Nice to have: Medicare Oasis Behavioral Health · Posted Nov 4, 2026
Monitor utilization of services for patients to optimize reimbursement for the facility.
Act as liaison between managed care organizations and the facility professional clinical staff Conduct reviews of insurance plans or other managed care organizations and coordinate communication concerning reimbursement requirements Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges and quality of services Conduct quality reviews for medical necessity and services provided High school diploma or equivalent Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field Nice to have: LPN Nice to have: RN Nice to have: LMSW Tenet Healthcare Corporation · Posted Nov 4, 2026
Lead physician advisor role supporting hospital administration and clinical teams to improve patient care quality and operational outcomes.
Perform secondary physician reviews and medical necessity determinations Conduct peer-to-peer discussions with payer medical directors Support denial prevention, appeal, and overturn activities Collaborate with case management and utilization management teams regarding level-of-care determinations Provide physician leadership and support for utilization management initiatives and committees Doctor of Medicine Degree (M.D.) Doctor of Osteopathic Medicine Degree (D.O.) Medical Dental Vision Life Insurance Short-Term and Long-Term Disability
Medical Dental Vision Life Insurance Short-Term and Long-Term Disability
Health insurance 401K Stock purchase plans Tuition reimbursement Paid time off
Base salary $150-$200 per hour 401(k) Retirement Saving Plan with employer match
Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program
Utilization SpecialistAcadia Healthcare · Hudson, US
Utilization Management Nurse Specialist RN II (ALD)L.A. Care Health Plan · Los Angeles, US
Physician AdvisorTenet Healthcare Corporation · US