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Manager Utilization Management Jobs in Rio Rancho, NM

VIVA USA INC

Utilization Review Nurse

Albuquerque, NM · On-site +1

... Utilization Management Requirements And Operational Procedures To Members, Providers And Facilities ... Serve as liaison between providers and Medical and Network Management Divisions. 3.Review service ...

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All JobsManager Utilization Management JobsManager Utilization Management Jobs in Rio Rancho, NM

Manager Utilization Management information

See Rio Rancho, NM salary details

$36.7K

$85.6K

$157.6K

How much do manager utilization management jobs pay per year?

As of Jun 19, 2026, the average yearly pay for manager utilization management in Rio Rancho, NM is $85,606.00, according to ZipRecruiter salary data. Most workers in this role earn between $56,000.00 and $103,000.00 per year, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Manager Utilization Management, and why are they important?

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 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 some common challenges faced by a Manager in 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 does a Manager of 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 popular job titles related to Manager Utilization Management jobs in Rio Rancho, NM? For Manager Utilization Management jobs in Rio Rancho, NM, the most frequently searched job titles are:
What job categories do people searching Manager Utilization Management jobs in Rio Rancho, NM look for? The top searched job categories for Manager Utilization Management jobs in Rio Rancho, NM are:
What cities near Rio Rancho, NM are hiring for Manager Utilization Management jobs? Cities near Rio Rancho, NM with the most Manager Utilization Management job openings:
Manager Utilization Management jobs near you
Infographic showing various Manager Utilization Management job openings in Rio Rancho, NM as of June 2026, with employment types broken down into 1% As Needed, 96% Full Time, 1% Part Time, and 2% Contract. Highlights an 92% Physical, 2% Hybrid, and 6% Remote job distribution, with an average salary of $85,606 per year, or $41.2 per hour.
LTC Utilization Management Reviewer

LTC Utilization Management Reviewer

Presbyterian Healthcare Services

Albuquerque, NM • On-site

Full-time

Medical, Dental, Vision, Life

Posted 5 days ago

Presbyterian Healthcare Services rating

7.3

Company rating: 7.3 out of 10

Based on 158 frontline employees who took The Breakroom Quiz

256th of 873 rated healthcare providers

Job description

Location Address:
9521 San Mateo NEAlbuquerque, NM 87113-2237
Compensation Pay Range:
Minimum Offer $0.00Maximum Offer $0.00Now Hiring: LTC Utilization Management Reviewer
Summary:
Build your Career. Make a Difference. Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team.Type of Opportunity: Full timeJob Exempt: YesJob is based: Reverend Hugh Cooper Administrative CenterWork Shift: Days (United States of America)
Responsibilities:
Now hiring a Utilization Management Reviewer-LTC
Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria. Performs utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting. Utilizes LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets. Validates and interprets documentation using approved LTSS criteria. Consults with PHP medical directors and refers for medical director decisions on cases not meeting LTSS criteria, NF LOC denials and care plans that result in a reduction in service or benefit denial. Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud
Some key responsibilities include:
  • NF LOC evaluations and determinations,
  • Responsible for the review of all required medical documentation against HSD criteria and to provide an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).
  • Documents recommendations and NF LOC determinations (approvals, request for more information and denials in PHPs case management system, including appropriate documentation of authorization and NF LOC begin and end date eligibility spans according to established HSD policies. Refers all NF LOC denials to the health plans medical director for review.
  • Prepares files and participates in state fair hearing procedures.
  • Reviews agency-based community benefit care plans for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
  • Documents Agency-based community benefit care plan approvals, partial approvals and denials in PHPs case management system according to policies and procedures and job-aids.
  • Reviews self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
  • Reviews care plans to assure the overall cost of the community benefit care plan does not exceed the overall cost of care in a nursing home based on the benchmark provided by HSD.
  • Documents self-directed community benefit care plan and budget approvals, partial approvals and denials in PHPs case management system and the Fiscal Management agencys information system according to policies and procedures and job-aids.

Qualifications:
  • Active Nursing license in NM or compact license (RN or LPN) with a minimum of one year of relevant experience
  • Medical Social Worker with a minimum of one year of relevant experience; or
  • Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.
  • Prefer 1 year of experience in MCO, health plan insurance environment , with expertise performing utilization management or experience working in long term care services
  • Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
  • Analytical skills as applicable to interpret provider communication and medical records.
  • Attention to detail and organizational skills.
  • Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best
  • representing the organization professionally.
  • Ability to work cooperatively with other employees and departments.
  • Efficient and comfortable with computer electronic data entry and documentation
  • Ability to succinctly document using correct spelling and grammar.
  • Able to summarize from medical clinical notes, progress notes, needs assessments, functional assessments, progress notes, history and physicals , care plans and other state required documentation.
  • Able to meet timelines and deadlines associated with work load.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services

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About Presbyterian Healthcare Services

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Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Albuquerque, NM, US

Year founded

1908

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