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Utilization Care Manager Jobs in Kentucky (NOW HIRING)

P3 Health Partners, Inc.

$100 - $140/hr

P3 Health Partners is seeking a Utilization Management Manager to oversee the daily operations of ... Maintain expertise in Medicare Advantage regulations, managed care requirements, and provider ...

Texas Health Resources, Inc.

$70 - $90/hr

#Registered Nurse Outpatient Care Manager - PRN3. Registered Nurse Outpatient Care Manager ... Utilization Management and pre-authorization experience preferred* RN upon hire required and* CCM ...

UnitedHealth Group

Patient Care Manager

Louisville, KY · On-site

$85K - $127K/yr

The Home Health Patient Care Manager and RN Hybrid is responsible for the supervision and ... utilization of services and resources * Provides clinical leadership through supervision ...

AbsoluteCARE Medical Center & Pharmacy

$150 - $210/hr

Supervises, leads a CM Program Manager, TCM program lead , two Clinical Educators, and three ... Monitor and optimize care and utilization management workflows, staffing models, and performance ...

UnitedHealth Group

Patient Care Manager

Louisville, KY · On-site

$85K - $127K/yr

The Home Health Patient Care Manager and RN Hybrid is responsible for the supervision and ... utilization of services and resources * Provides clinical leadership through supervision ...

TEEMA Group

RN Care Manager

Owensboro, KY · On-site

Participate actively in team meetings, quality improvement projects, and utilization review ... Familiarity with managed care environments, quality metrics, and cost-effective care models.

Providence Swedish Medical Center

$66 - $124/hr

Accountabilities include assessment and planning, coordination of care, resource utilization management and/ or review, discharge planning, documentation of interventions, regulatory compliance and ...

Anacalifornia

$120 - $170/hr

Experience in value‑based care, population health, or utilization management * Knowledge of Medi‑Cal, HEDIS, P4P, and quality improvement methodologies * Experience with Arcadia or similar care ...

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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 Kentucky?

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

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

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

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

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

Utilization Care Manager jobs near you

Care Manager

Appalachian Regional Healthcare, Inc.

Paintsville, KY • On-site

Full-time

Re-posted 12 days ago

Appalachian Regional Healthcare rating

6.5

Company rating: 6.5 out of 10

Based on 74 frontline employees who took The Breakroom Quiz

609th of 895 rated healthcare providers

Job description

Overview
The Care Manager is accountable for outcomes as related to providing coordination of patient management through the continuum of care. Responsible for financial, clinical, and discharge planning evaluation for each assigned patient. Assures payment for services rendered, coordinates care, manages resources, and facilitates each patient encounter for efficient and effective outcomes as related to quality, clinical and cost areas.
Responsibilities
  • Manages an assigned caseload of patients from preadmission to discharge.
  • Assumes responsibility for admission appropriateness (medical necessity), (outpatient, observation, inpatient admission), continued stay, and medical record monitoring.
  • Coordinates communication with third party payers, external review agencies and the Utilization Committee.
  • Identify managed care issues and address promptly as related to denials management.
  • Coordinates and collaborate with physicians, provider, multidisciplinary team and other health care professionals concerning patient's goals, plan of care and progress.
  • Revise and adjust on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.
  • Leads discharge planning multidisciplinary team meetings, ensures documentation of meetings.
  • Advocate for the patient/family and is knowledgeable of and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.
  • Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills. Care Management is willing to seek certification in case management field if made available through ARH.
  • Stays abreast of regulatory agency guidelines as pertains to area of practice
  • Initiate and monitor clinical care guidelines and analyze positive and negative variances
  • Ensure continuity of care through formulation of discharge plan on admission and follow though until patient is discharged.
  • Ensure appropriate use of resources.
  • Monitor patient care for appropriate use of resources.
  • Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff, and others to overcome barriers to discharge.
  • Monitors in-house denials for extended lengths of stay.
  • Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.
  • Participates as a member of the Utilization Committee
  • Assists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
  • Participates in data collection, specific to outcomes data.
  • Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.
  • Performs other related duties as assigned.

Qualifications
Required Education
  • Associate Degree in Nursing from an accredited school of nursing and current Registered Nurse (RN) licensure in the state of employment preferred.
  • Bachelor of Science in Nursing (BSN) preferred and must be obtained within five (5) years of hire.
Preferred Experience
  • Four (4) to six (6) years of nursing experience preferred.
  • Five (5) years of nursing experience may be considered with demonstrated skills required for the position.
Required Skills, Knowledge, and Abilities
  • Advanced problem-solving and decision-making skills.
  • Strong multitasking abilities with the ability to manage competing priorities and deadlines; flexible and adaptable.
  • Ability to interact tactfully and professionally with patients, families, staff, and community members.
  • Advanced communication skills with the ability to lead and support a team.
  • Advanced planning, execution, delivery, and operational support skills.
  • Ability to evaluate the relative costs and benefits of potential actions and make sound decisions.
  • Ability to function effectively in a clinical setting with diverse patient populations and healthcare teams.
  • Mastery of care transition processes and available patient resources.
  • Strong digital literacy and technology skills.
  • Ability to handle sensitive and confidential information ethically and responsibly.
Licenses and Certifications
Required
  • Licensed Practical Nurse (LPN) licensure.
Preferred
  • Registered Nurse (RN) licensure.

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