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Manager Utilization Management Jobs in New York (NOW HIRING)

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Manager Utilization Management information

What does a manager utilization management do?

A Manager of Utilization Management oversees the process of evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead a team that reviews medical claims and care plans to ensure compliance with clinical guidelines and regulatory requirements. Their role often involves collaborating with physicians, nurses, insurance companies, and other stakeholders to optimize patient outcomes while managing healthcare costs. Additionally, they are responsible for implementing policies, training staff, and ensuring that utilization management activities align with organizational goals.

What are the key skills and qualifications needed to thrive as a manager utilization management?

To thrive as a Manager Utilization Management, you need a thorough understanding of healthcare regulations, utilization review processes, and case management, often supported by a clinical degree (such as RN) and relevant experience. Familiarity with utilization management software, claims processing systems, and potentially certifications like CCM (Certified Case Manager) or ACM (Accredited Case Manager) is important. Strong leadership, analytical thinking, and effective communication help you guide teams and collaborate with providers and payers. These skills ensure efficient resource use, compliance, and quality patient care within managed care organizations.

What are some common challenges faced by a manager utilization management, and how can they effectively address them?

Managers in Utilization Management often encounter challenges such as balancing quality patient care with cost containment, navigating evolving healthcare regulations, and managing diverse teams. To effectively address these issues, successful managers develop strong communication skills, stay updated on industry standards, and foster collaboration between clinical and administrative staff. Implementing robust training programs and utilizing data-driven decision-making can also help ensure compliance and improve overall team performance.

What is the difference between Manager Utilization Management vs Utilization Review Nurse?

AspectManager Utilization ManagementUtilization Review Nurse
CredentialsRN, often with management or utilization review certificationsRN, with certifications in utilization review or case management
Work EnvironmentSupervises teams, manages policies, oversees utilization review processesPerforms patient chart reviews, assesses medical necessity, collaborates with providers
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare organizations
Search & Comparison IntentYesYes

While both roles focus on utilization review, the Manager Utilization Management oversees teams and policies, ensuring efficient resource use, whereas the Utilization Review Nurse conducts patient-specific reviews to determine medical necessity. The manager role involves leadership and strategic planning, while the nurse role is more clinical and review-focused.

What are the most commonly searched types of Utilization Management jobs in New York?

The most popular types of Utilization Management jobs in New York are:

What are popular job titles related to Manager Utilization Management jobs in New York?

For Manager Utilization Management jobs in New York, the most frequently searched job titles are:

What job categories do people searching Manager Utilization Management jobs in New York look for?

The top searched job categories for Manager Utilization Management jobs in New York are:

What cities in New York are hiring for Manager Utilization Management jobs?

Cities in New York with the most Manager Utilization Management job openings:

Manager Utilization Management jobs near you
Infographic showing various Manager Utilization Management job openings in New York as of August 2026, with employment types broken down into 85% Full Time, and 15% Contract. Highlights an 100% In-person job distribution.

Utilization Management (UM) Clinical Team Lead (RN, LPN or PT)

MetroPlusHealth

Manhattan, NY • Hybrid

$124K - $124K/yr

Full-time

Posted 28 days ago

MetroPlusHealth rating

6.7

Company rating: 6.7 out of 10

Based on 9 frontline employees who took The Breakroom Quiz

276th of 315 rated insurance

Job description

Empower. Unite. Care.
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview:

The Clinical Team Lead, under the direction of the Vice President of Clinical Services, is primarily responsible for managing both simple and complex medical cases to achieve high-quality patient care outcomes and minimize unnecessary medical expenses, through the coordination of services, both outpatient and inpatient. The Clinical Team Lead will assist the provider in directing care to the most appropriate setting, evaluating alternative care plans, and assessing outcomes through outreach to the members.

Work Shifts

9:00 AM - 5:00 PM

Duties & Responsibilities
  • Performs care management including hospital admission certification, continued stay review, discharge planning, outpatient, and ancillary services review, etc., following established MetroPlusHealth Utilization Management policies, procedures, and protocols.
  • Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.
  • Interacts and obtains relevant clinical information from members' PCP and other providers; approves care that meets established criteria; and refers all other cases to the MetroPlusHealth Physician Advisor/Medical Director.
  • Inform member and provider of Utilization Management determinations and treatment alternatives.
  • Identifies utilization trends and potential member needs by means of generating reports of encounter data, pharmacy data review, and new member health assessment forms.
  • Evaluate member needs for referred cases (from providers or member self-referred).
  • Assists all departments with the resolution of members' problems related to utilization management issues.
  • Performs all Utilization Management activities in compliance with all regulatory agency requirements.
  • Conducts medical record reviews as appropriate to case management functions.
  • Participate in Medical Management grand rounds with the Physician Advisor.
  • Performs all other duties as assigned
Minimum Qualifications
  • High School Diploma General Equivalency Diploma (GED) required; and
  • 2-5 years' clinical experience in an acute or applicable care setting.
  • UM/UR experience in managed care or hospital setting required

Licensure and/or Certification Required:

  • Valid New York State license and current registration to practice as a Registered Professional Nurse (RN), License Practical Nurse (LPN), or Physical Therapist (PT) issued by the New York State Education Department (NYSED).

Professional Competencies:

  • Integrity and Trust
  • Customer Focus
  • Excellent communication, written and analytical skills.
  • Knowledge of computer systems.

#LI-Hybrid #MPH50

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