From The Nontraditional Nurse
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​​April 1, 2026

Welcome back!
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This month’s spotlight is on a side of nursing that a lot of nurses have heard of, but not all fully understand: utilization management.

If you’ve ever been curious about prior auth, insurance-based roles, or how nurses use their skills behind the scenes to help patients get the right care at the right time, this edition is for you.
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The Nontraditional Nurse spotlight

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I sat down with Jessica Smith, LPN, who has built her career in prior authorization, clinical review, and utilization management after starting out in patient care. In this conversation, she breaks down what UM nurses actually do, how clinical judgment still plays a major role, what makes this path a good fit for some nurses, and why these jobs can be harder to find than they should be.

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Key Takeaways

It’s a bigger field than you think.

Utilization management includes roles like clinical review, prior authorization, case management, and more, but the job titles aren’t always obvious.
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​Clinical judgment still matters.

Even with national criteria guidelines, nurses are constantly using real clinical insight to advocate for what patients actually need.
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​This path is open to LPNs too.

Utilization management is a career path where LPNs are actively working and building long-term careers. Jessica is an LPN and has worked with other LPNs in all her UM roles.
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​Breaking in takes strategy.

Getting into UM often means learning the language, optimizing your LinkedIn, and sometimes taking a contract role to get your foot in the door.

Career Deep Dive

Utilization Management

At its core, utilization management (UM) nursing is about reviewing whether healthcare services are medically necessary, appropriate, and aligned with evidence-based guidelines.

Instead of providing hands-on care, UM nurses are reviewing patient charts, provider requests, and clinical documentation to determine if a treatment, procedure, or service meets specific criteria.

A large part of the role involves working with standardized guidelines like InterQual or MCG — but it’s not just checking boxes.

As Jessica explained:

“We’re always trying to make that chart fit into that criteria. And we’re trying to take care of our patients.”

That balance is what makes this role unique. There is structure, but there is also a lot of room for clinical judgment.
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“ There’s a big misconception with insurance… people think it’s us versus them… but we’re really trying to make sure the patient gets the appropriate care at the appropriate time. — Jessica Smith

What might a typical day look like?

Most UM nurses work in a queue-based system, where providers submit requests for things like imaging, procedures, medications, or services. This will vary based on setting (for example, inpatient versus outpatient).

A typical day might include:

• Reviewing incoming cases and prioritizing which need attention first
• Comparing clinical documentation to national criteria
• Identifying cases that meet criteria vs. those that require further review
• Sending cases to a physician (MD review) when criteria aren’t clearly met
• Requesting additional documentation from providers when needed
• Writing clinical summaries or determinations

In many cases, if something doesn’t clearly meet criteria, nurses can still advocate for the patient by building a case and escalating it.

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Perks

Remote Work and Flexibility
​Many UM roles are fully remote, which can offer a level of flexibility that’s hard to find in traditional bedside nursing.

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​Using your brain in a different way
​This role leans heavily on critical thinking, pattern recognition, and clinical judgment rather than physical tasks, which can be a refreshing shift.

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​A sustainable long-term career
​For nurses who are feeling burned out physically, UM offers a way to stay in healthcare without the physical demands of bedside care.

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​Exposure to a wide range of cases​
You get to review all kinds of patient scenarios, diagnoses, and treatments, which keeps the work interesting and constantly evolving. As Jessica shared: “It’s never boring. You always get something new.”

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​No scrubs, no weekends, no holidays (in many roles)
​While not universal, many positions offer more traditional schedules and remove some of the unpredictability that comes with shift work.

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​Accessible for different nursing backgrounds
​This is a nontraditional path where both RNs and LPNs can find opportunities and build long-term careers.

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Challenges

It can be hard to break into the field
​One of the biggest barriers is simply finding the jobs, since many roles are posted under different titles or through third-party recruiters.
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​Learning a whole new language
​UM comes with its own set of acronyms, criteria, and terminology, which can feel overwhelming at first and make the field harder to navigate. Starting to learn this language can be a big help during your job search!
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​It’s not always black and white
​Even with structured guidelines, there are gray areas where you have to make judgment calls, advocate, and sometimes sit with difficult decisions.
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​Perception of the role
​There can be a stigma around insurance-based roles, especially around denials, even though the reality is much more nuanced.

Remote work can feel isolating
​Without the built-in social environment of the bedside, some nurses struggle with the lack of in-person connection.
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Boundaries can be a challenge when working from home
​It can be difficult to separate work and home life, especially when others assume you’re available just because you’re home.
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Work-life balance

Work-life balance in utilization management can look very different from bedside nursing, but it’s not automatically “better” across the board. For many nurses, the biggest shift is moving into a more predictable schedule. Most roles follow standard business hours, which means no nights, fewer weekends, and more consistency in your day-to-day life.

That said, working from home brings its own set of challenges. Without a physical separation between work and home, it can be easy for the lines to blur. Jessica talked about how people may assume you’re available just because you’re home, and how important it is to set clear boundaries during your working hours.

There’s also a social component to consider. You lose that built-in camaraderie that naturally comes with bedside nursing, and for some people, that adjustment can be harder than expected. Staying connected with coworkers takes more intention, and outside social interaction becomes more important.

At the same time, many nurses find that this type of role allows them to build a more sustainable routine. You’re able to step away from the physical demands of bedside care while still using your nursing knowledge in a meaningful way. Like most things, it comes down to fit. For the right person, this kind of balance can be exactly what they’ve been looking for.

Nursing Skills that Translate

It’s important to note that you don’t need a completely new skillset to move into utilization management. In fact, a lot of what makes you a strong bedside nurse is exactly what makes you successful in this role.​
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• Clinical Judgement: You’re constantly assessing whether something makes sense clinically. In UM, that shows up as determining medical necessity and recognizing when a case may need escalation or further review.
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• Patient Advocacy: Even though you’re not at the bedside, you’re still advocating every day. Sometimes that means building a case for approval when something doesn’t clearly meet criteria but is still the right thing for the patient.
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• Patient Education: This translates directly into explaining complex decisions in a way patients can actually understand. As Jessica shared: “We have to translate denial letters into fifth grade language.”
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• Attention to detail: You’re reviewing charts, documentation, and criteria line by line. Small details can completely change the outcome of a case.
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• Communication skills: There’s a lot of back-and-forth with providers, teammates, and sometimes physicians reviewing cases. Being clear, concise, and confident matters.
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• Curiosity about systems: Nurses who naturally ask “how does this work?” tend to do really well here. Understanding insurance processes and digging into the “why” behind decisions is a huge advantage.

These are all things you’re probably already doing. You’re just applying them in a different setting.

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How Much Experience Do you Need?

This is one of those roles where there isn’t a single, clear-cut answer, but the good news is you likely don’t need as much as you think.

Many utilization management and prior authorization roles don’t require decades of bedside experience. Nurses often transition after a few years once they’ve built a strong clinical foundation and feel confident in their assessment and decision-making skills. What matters most is your ability to think critically, understand patient care, and apply that knowledge to determine medical necessity.

Jessica’s path is a great example of how this can happen more organically than you might expect. She didn’t set out to work in UM—her exposure to insurance processes in an outpatient clinic is what ultimately opened the door. That touchpoint with prior authorizations became the bridge into case management and eventually into her current role.

For nurses trying to break in, experience with anything insurance-related can be a huge advantage. That could include:

• Outpatient or clinic settings
• Prior authorizations or referrals
• Discharge planning or case management
• Coordinating care with insurance companies

And if you don’t have that experience yet, it doesn’t mean you’re out. Jessica emphasized that getting your foot in the door—often through a contract role or recruiter—is one of the most common ways people enter the field.

Bottom line: you need enough clinical experience to think like a nurse—but you don’t need a perfect background to get started.

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Salary

Salary in utilization management and prior authorization can vary based on experience, credentials (LPN vs RN), company, and the specific type of role (UM, case management, appeals, concurrent review, etc.).

In general, LPNs in these roles often fall around $55,000–$75,000, while RNs more commonly range from $70,000–$95,000+, with higher earning potential in senior reviewer, specialty, or leadership positions.

According to Glassdoor utilization review nurse salary data, the average salary for a utilization review nurse in the U.S. is typically in the mid-$80,000 range, though this can vary widely depending on the company and location.

One thing Jessica mentioned is that breaking into the field doesn’t always come with an immediate pay bump. Some nurses take a contract role or slight pay cut initially to gain experience, but that often leads to more stable, higher-paying opportunities once you’re established.

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What to search for when job hunting.

One of the biggest challenges with this field is that the job titles aren’t always obvious.

As Jessica pointed out, many roles don’t actually say “utilization management” or “prior authorization” in the title.

Other titles to search for include:

• Clinical Review Nurse
• Case Manager
• Appeals Nurse
• Concurrent Review Nurse (often inpatient-focused)

There are also adjacent roles in claims, billing, and even disability or life insurance review.

Final Thoughts

Jessica pointed out something that’s really important to understand going in—many companies hire new UM nurses on a contract or trial basis first.

That can feel a little scary, especially if you’re coming from a stable bedside role and stepping into something with a set timeline. In a lot of cases, those roles do turn into permanent positions if it’s a good fit, but it’s not guaranteed. It’s important to really think through your own risk tolerance before making that jump.

That said, this is also one of the most common ways people break into the field. Getting that first bit of UM experience can open a lot of doors, and once you have it, it becomes much easier to land other roles in this space.

Your laughter injection.

What did the cookie say to the nurse? "I feel crumby"

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Appreciate you being here,

Ellie