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Utilization Care Manager Jobs in Georgia (NOW HIRING)

Phoebe Putney Health System

... Utilization review duties in Care Management. Timely communication of clinical information and updates will be provided to the insurance companies as requested or required by contract or federal and ...

Acadia Healthcare

Utilization Specialist

Riverdale, GA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.

Ova Technologies

Utilization Review Nurse

Alpharetta, GA · On-site

Utilization Review Nurse Location: [City, State / Remote] Employment Type: Full-Time Experience: 2 ... Communicate with insurance companies, managed care organizations, and third-party payers regarding ...

LCMC Health

This role ensures appropriate use of healthcare services, regulatory compliance, and optimal ... Provide direct oversight to UM manager and clinical review staff. * Establish productivity ...

Acadia Healthcare

Utilization Specialist

Valdosta, GA · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.

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Utilization Care Manager information

What is a utilization care manager?

Utilization Care Managers are healthcare professionals responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They work to ensure that patients receive the right care at the right time, while also helping healthcare organizations manage costs and comply with regulations. Utilization Care Managers often review patient cases, coordinate with medical staff, and interact with insurance companies to authorize or deny services. Their goal is to optimize healthcare delivery, reduce unnecessary procedures, and improve patient outcomes.

How does a utilization care manager collaborate with medical and administrative teams to ensure effective patient care?

Utilization Care Managers work closely with physicians, nursing staff, and administrative teams to review patient cases, determine medical necessity, and coordinate appropriate care plans. They frequently participate in interdisciplinary meetings, communicate with insurance providers regarding authorizations, and ensure compliance with regulatory guidelines. This collaborative approach helps to optimize resource utilization, improve patient outcomes, and support smooth transitions of care. Being proactive in communication and documentation is key to success in this role.

What are the key skills and qualifications needed to thrive as a utilization care manager, and why are they important?

To thrive as a Utilization Care Manager, you need a background in healthcare, typically as a registered nurse or social worker, with expertise in care coordination and utilization review. Familiarity with utilization management software, medical necessity guidelines (such as Milliman or InterQual), and knowledge of insurance regulations are important. Strong analytical thinking, attention to detail, and effective communication skills help you advocate for patients while working with healthcare teams and payers. These skills ensure appropriate resource use, quality patient outcomes, and compliance with regulatory standards.

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

AspectUtilization Care ManagerUtilization Review Nurse
CredentialsRN, case management certificationRN, certification in utilization review
Work EnvironmentHealthcare facilities, insurance companiesHospitals, insurance companies, outpatient clinics
Primary FocusCoordinating patient care, managing resourcesReviewing medical necessity, approving treatments

Utilization Care Managers focus on coordinating patient care and managing resources, while Utilization Review Nurses primarily evaluate medical necessity for treatments. Both roles require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.

What does a utilization care manager do in healthcare?

A utilization care manager in healthcare reviews patient cases to ensure appropriate use of medical services and resources, coordinating care plans to optimize patient outcomes and reduce unnecessary costs. They often work with healthcare providers, insurance companies, and patients, using data and clinical guidelines to make informed decisions about treatment and service utilization.

What are popular job titles related to Utilization Care Manager jobs in Georgia?

For Utilization Care Manager jobs in Georgia, the most frequently searched job titles are:

What job categories do people searching Utilization Care Manager jobs in Georgia look for?

The top searched job categories for Utilization Care Manager jobs in Georgia are:

What cities in Georgia are hiring for Utilization Care Manager jobs?

Cities in Georgia with the most Utilization Care Manager job openings:

Utilization Care Manager jobs near you

RN, UR Specialist - Weekend Shift (In House Preferred) or Remote

Phoebe Putney Health System

On-site, Remote

Full-time

Posted 6 days ago

Job description

Job Number:
34782
Location:
Phoebe Putney Memorial Hospital
Street Address:
417 W 3rd Ave
City, State:
Albany, Georgia
Zip Code:
31701
Department:
PPMH CARE MANAGEMENT
Shift:
First Shift
Job Type:
Full time
Posted Date:
2026-08-13
Job Description Summary:
Description:
JOB SUMMARY
  • The primary responsibilities of the RN UR Specialist include performing activities related to insurance company notifications, obtaining certifications and authorizations related to Utilization review duties in Care Management. Timely communication of clinical information and updates will be provided to the insurance companies as requested or required by contract or federal and state regulations in support of medical necessity justification and hospital billing and payment for patient care and services rendered. He/she will liaison with third party payers regarding UR requirements, authorization or denial matters, and will assist with complex authorization needs impacting patient transition planning. Proactive communication with Care Manager and Social Work staff will foster coordination and a team approach for key care management functions and meeting patient needs. Will notify Care Managers of potential denials and communicate with patient physician and payer medical director for peer to peer discussions. This position will be on-site.
    EDUCATION
    Associate's Degree in Nursing (Required)
    Bachelor's Degree in Nursing (Preferred)
    EXPERIENCE
    3+ Recent and relevant acute clinical care experience (Required)
    1+ Utilization review experience in a hospital, managed care or physician office practice setting (Required)
    CERTIFICATIONS/LICENSURES
    Registered Nurse (RN) in the state of Georgia (Required)
    Certified Case Manager (Preferred)
    Certified Professional Utilization Review (Preferred)
    ESSENTIAL FUNCTIONS
    UTILIZATION REVIEW -RN:
    Completes utilization review functions on assigned caseload or area and serves as a resource for CM staff, physicians and other staff. Functions as liaison and resource regarding updates in payer requirements and hospital processes. Assures appropriate authorizations for patient level of care and works to avert potential payer denials.
    Notifies Physician offices of required notification, precertification or authorizations as necessary.
    Communicates pertinent clinical information to insurance companies as needed.
    Communicates all relevant information to the appropriate Care Management staff. Notifies attending physicians of potential insurance company denials; may take verbal orders for change in patient status.
    Notifies attending physicians of potential insurance company denials and coordinated peer to peer physician case review.
    Participates in data collection as directed by the Care Management Director. Ensures accuracy, timeliness and integrity of data. Identifies any performance improvement opportunities, proposes resolutions, and records on appropriate forms.
    Coordinates with the unit Care Managers, Social Workers and CM staff to assure payer decisions are known and actions taken as needed to prevent denials or patient liability.
    Works closely with Patient Accounts and Revenue Cycle areas to address payer issues and reconciliations of accounts as needed.
    UR DOCUMENTATION & ELECTRONIC SYSTEM:
    Documents and records review activity, follow up and outcomes in the appropriate electronic system as required; assures documented/recorded information and data are timely and inclusive of pertinent facts.
    Clearly and accurately documents UM related reviews, referrals, activities related to utilization review, approvals, denials, avoidable delays and outcomes.
    Ensures that documentation is tailored to expected readers / users.
    Uses correct terminology in accordance with hospital standards and conforms to required style and format.
    Applies medical staff approved clinical criteria to reviews and in accordance with payer standards and requirements
    Utilizes applicable payer portals to input clinical information, secure notifications and approvals. Researches sites for updated manuals, bulletins and requirements and communicates changes within Care Management department, to Director and Chief Utilization Officer.
    CM / UM LEADERSHIP:
    Engages in teamwork as a team player and a team leader. Educates staff, physicians and patients about the role of UR Specialist and changing payer trends and requirements.
    Serves on committees or participates in projects at work with opportunities for shared decision making and being a change agent.
    Promotes professionalism of role through participation in professional organizations and/or research in utilization management.
    Incorporates evidence based knowledge in practice.
    ADDITIONAL DUTIES
    Adheres to the hospital and departmental attendance and punctuality guidelines.
    Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
    Performs other duties as required and completes all job functions as per departmental policies and procedures.
    Maintains current Knowledge in present areas of responsibility to include any specialty certification requirements (i.e., self-education, attends ongoing educational programs).
    Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
    Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs. For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.
    Wears protective clothing and equipment as appropriate.

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