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Medicare Utilization Management Program Manager Jobs

StoneCrest Center

Utilization Manager

Detroit, MI · On-site

Three or more years' clinical experience with the population of the facility and previous experience in Utilization Mgmt. Qualifications * LICENSES/DESIGNATIONS/CERTIFICATIONS: If applicable, current ...

New

Clarvida - Georgia

Utilization Manager

Savannah, GA · On-site

Performs Utilization Management reviews, to include On Hold reports, and coordinates resolution of ... Employee Assistance Program * Health, Dependent and Transportation Flexible Spending Accounts

Pacific Health Group

CA

$80K - $85K/yr

ECM Program Manager Pacific Health Group | Transforming Care Through Connection At Pacific Health ... Experience with Medicaid/Medicare programs and ECM program requirements. * Strong analytical skills ...

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Medicare Utilization Management Program Manager information

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$167.5K

How much do medicare utilization management program manager jobs pay per year?

As of Sep 11, 2026, the average yearly pay for medicare utilization management program manager in the United States is $91,011.00, according to ZipRecruiter salary data. Most workers in this role earn between $59,500.00 and $109,500.00 per year, depending on experience, location, and employer.

What is a Medicare Utilization Management Program Manager?

A Medicare Utilization Management Program Manager is a healthcare professional responsible for overseeing and optimizing the use of medical services for Medicare beneficiaries. They ensure that patients receive appropriate, necessary, and cost-effective care by developing and managing utilization review processes, complying with federal regulations, and coordinating with healthcare providers. Their role includes analyzing healthcare data, implementing policies to prevent unnecessary services, and maintaining quality standards within the Medicare program. They often work for insurance companies, healthcare organizations, or government agencies.

How does a Medicare Utilization Management Program Manager collaborate with clinical and administrative teams to ensure effective care delivery?

As a Medicare Utilization Management Program Manager, you will regularly coordinate with clinical staff, such as nurses and physicians, to review patient cases and ensure that care provided aligns with Medicare guidelines. You’ll also work closely with administrative teams to implement process improvements, monitor compliance, and analyze utilization data. Effective communication and cross-functional collaboration are key, as you’ll often facilitate meetings, provide training, and resolve issues that arise between departments. This collaborative environment helps ensure that members receive appropriate, cost-effective care while maintaining regulatory compliance.

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

To thrive as a Medicare Utilization Management Program Manager, you need expertise in healthcare management, regulatory compliance, and utilization review, typically supported by a clinical background (such as RN or LPN) and a bachelor's or master's degree in a health-related field. Familiarity with Medicare guidelines, claims processing systems, and utilization management software is essential, and certification such as CCM (Certified Case Manager) can be advantageous. Strong leadership, analytical thinking, and effective communication skills help coordinate teams, interpret policies, and ensure quality outcomes. These skills and qualifications are crucial for maintaining compliance, optimizing resource use, and ensuring members receive appropriate, cost-effective care.

What are popular job titles related to Medicare Utilization Management Program Manager jobs?

For Medicare Utilization Management Program Manager jobs, the most frequently searched job titles are:

Infographic showing various Medicare Utilization Management Program Manager job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 79% Full Time, 16% Part Time, and 4% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $91,011 per year, or $43.8 per hour.

Utilization Management Specialist

Kent, OH

Coleman Health Services
Offices of Mental Health Practitioners • 501 - 1,000 employees
Learn more about Coleman Health Servicesexternal

$60K/yr

Full-time

Medical, Dental, Vision, PTO

Posted 11 days ago

Key responsibilities

  • Evaluate the medical necessity, clinical appropriateness, and efficiency of mental health and substance use disorder treatments.

  • Develop and implement processes for obtaining prior authorizations and utilization management strategies in accordance with industry best practices and regulatory requirements.

  • Collaborate with treatment providers, insurance companies, and other healthcare professionals to evaluate treatment plans, secure authorization, and ensure timely reimbursement.

Coleman Health Services rating

6.5

Company rating: 6.5 out of 10

Based on 9 frontline employees who took The Breakroom Quiz

Job description

Would you like to be part of an award-winning team where you can make a real difference? Coleman Health Services is dedicated to serving our communities and positively impacting the lives of our employees and the people they work to serve. If you are someone who believes in the value of achieving excellence, we want you on our team! As the Utilization Management Specialist, you will evaluate the medical necessity, clinical appropriateness and efficiency of mental health and substance use disorder treatments. Operating as a critical link between treatment providers and insurance payors, this position secures authorization to maximize reimbursement while ensuring clients receive optimal and appropriate care. This position can be based in any Coleman location, with preference of Kent, OH.

What can Coleman offer you as the Utilization Management Specialist?

  • Pay starting at $60,000, commensurate with experience
  • A positive environment that values teamwork, individuality, innovation, inclusivity, and where we embrace diversity
  • Flexibility and empowerment
  • You will be encouraged to participate in ongoing learning & developmental opportunities
  • Health, dental, vision insurance
  • Accrue three weeks of paid time off during first year
  • Wellness Reimbursement & more!

What are we looking for from you?

  • Develop and implement process for obtaining prior authorizations for client care.
  • Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
  • Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
  • Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
  • Collaborate with Revenue Cycle Management Director regarding claims payments, denials, and payor-based audits.
  • Analyze utilization data and trends to identify opportunities for improving care and reducing non-payment of claims.
  • Provide coverage for Compliance Officer during periods of absence

What qualifications will you need to be successful in this role?

  • Bachelor's degree in Social Work, Counseling, Psychology or Nursing.
  • Current relevant State of Ohio professional licensing
  • 5 years experience in behavioral health or related field
  • Demonstrated knowledge of current and best practices within behavioral health services
  • Demonstrated knowledge of State of Ohio Medicaid Behavioral Health Provider Manual
  • Demonstrated proficiency and experience working on an Electronic Health Record System
  • Demonstrated ability with Windows and Microsoft Office products
  • Exceptional organizational skills and attention to detail

Preference given to the following candidates:

  • Master's degree in Social Work, Counseling, Psychology or Nursing.
  • 5 years experience in Utilization Management or Quality Assurance
  • Current certification in Utilization Management, Compliance or Quality Assurance
  • Demonstrated ability with development of Power BI dashboards and/or SQL

Why join Coleman Health Services?

We are a nationally recognizednot-for-profit provider of behavioral health and an organization that has demonstrated over 40 years of stability and transparency.

Our Company Culture and Benefits Set Us Apart! Regardless of your role at Coleman Health Services, your work makes a lasting impact on those we serve. When you join our team, you become part of a collaborative community of dedicated professionals whose primary mission is to improve the lives of our clients. In return, you can also expect opportunities for career advancement and continued professional training.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. E.O.E. Persons with a disability can request an accommodation to complete the application process by emailing careers@colemanservices.org with the subject line "Accommodation Request." Coleman Health Services complies with the Federal Drug-Free Workplace Act.

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