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Manager Utilization Management Jobs in Philadelphia, PA

IntePros

Utilization Management RN

Philadelphia, PA · On-site

This role is responsible for performing utilization management reviews to determine the medical necessity of requested healthcare services, ensuring members receive appropriate, evidence-based care ...

divvyDOSE

Utilization Management Nurse RN

Broomall, PA · On-site

$60K - $107K/yr

Utilization Management Nurse Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly ...

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All JobsUtilization Management JobsManager Utilization Management JobsManager Utilization Management Jobs in Philadelphia, PA

Manager Utilization Management information

See Philadelphia, PA salary details

$39.4K

$91.8K

$169K

How much do manager utilization management jobs pay per year?

As of Aug 24, 2026, the average yearly pay for manager utilization management in Philadelphia, PA is $91,838.00, according to ZipRecruiter salary data. Most workers in this role earn between $60,000.00 and $110,500.00 per year, depending on experience, location, and employer.

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 Philadelphia, PA?

The most popular types of Utilization Management jobs in Philadelphia, PA are:

What are popular job titles related to Manager Utilization Management jobs in Philadelphia, PA?

For Manager Utilization Management jobs in Philadelphia, PA, the most frequently searched job titles are:

What job categories do people searching Manager Utilization Management jobs in Philadelphia, PA look for?

The top searched job categories for Manager Utilization Management jobs in Philadelphia, PA are:

What cities near Philadelphia, PA are hiring for Manager Utilization Management jobs?

Cities near Philadelphia, PA with the most Manager Utilization Management job openings:

Manager Utilization Management jobs near you
Infographic showing various Manager Utilization Management job openings in Philadelphia, PA as of August 2026, with employment types broken down into 84% Full Time, and 16% Contract. Highlights an 100% In-person job distribution, with an average salary of $91,838 per year, or $44.2 per hour.

RN - Utilization Management Quality Review

IntePros

Philadelphia, PA • On-site

Other

Posted 4 days ago

Job description

RN - Utilization Management Quality Review
Location: Remote; candidates must reside in the Tri-State area
Licensure: Active Pennsylvania RN license required
Position Summary
The RN is responsible for supporting quality and compliance within Utilization Management operations. This role reviews clinical documentation, medical necessity determinations, and member communications to ensure accuracy and compliance with applicable regulatory and accreditation requirements, including NCQA, CMS, and state-specific standards. The RN will conduct quality reviews of Utilization Management cases to confirm that clinical staff are appropriately applying InterQual criteria, medical policies, and departmental guidelines, making appropriate referrals to Medical Directors, and documenting cases accurately for member letter generation. This position also supports ongoing NCQA activities, audits, regulatory initiatives, and other quality improvement projects.
Key Responsibilities
  • Review applicable NCQA, CMS, and state regulations and standards and ensure appropriate operational controls are in place.
  • Identify compliance gaps and recommend or support implementation of corrective measures when needed.
  • Perform ongoing sample case reviews to evaluate the quality and accuracy of Utilization Management decisions and documentation.
  • Ensure clinical staff are correctly applying InterQual criteria, medical policies, and departmental guidelines.
  • Review cases referred to Medical Directors to ensure referrals are appropriate and include relevant, complete clinical information needed to support medical necessity determinations.
  • Conduct quality reviews of member letters to ensure documentation is clear, accurate, understandable, and compliant with regulatory requirements.
  • Verify that clinical staff document appropriately within the medical management system to support accurate letter generation.
  • Identify quality, compliance, and efficiency trends through audit findings and report findings to management.
  • Support NCQA surveys, annual documentation preparation, maintenance activities, and other regulatory projects.
  • Serve as a knowledgeable resource for internal and external stakeholders, providing timely and professional communication.
  • Maintain strong attention to detail while managing multiple priorities and compliance requirements.
Qualifications:
  • Active and unrestricted Pennsylvania Registered Nurse (RN) license required.
  • Minimum of 5 years of clinical nursing experience.
  • BSN preferred.
  • Previous experience with Utilization Management, Utilization Review, or Care Management strongly preferred.
  • Moderate to strong knowledge of InterQual criteria required.
  • Experience working with Utilization Management or medical management systems.
  • Knowledge of NCQA, CMS, state regulatory requirements, and other healthcare compliance standards.
  • Experience reviewing clinical documentation, medical necessity determinations, and/or regulatory member communications preferred.
  • Excellent written and verbal communication skills with exceptional attention to detail.
  • Strong analytical, problem-solving, organizational, and planning skills.
  • Ability to provide constructive feedback while maintaining positive and productive working relationships.
  • Proficiency with Microsoft Excel, PowerPoint, and Word.
  • Ability to work effectively in a remote environment while managing competing priorities and deadlines.
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