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Utilization Care Manager Jobs in Rhode Island (NOW HIRING)

Care New England

Transitions RN Care Manager

Warwick, RI · On-site

$90 - $120/hr

Applies Case Management principles to the acute care in-patient population to ensure appropriate utilization of resources and level of care. This includes assessing, planning, implementing ...

Brownhealth

MDC Coordinator

Providence, RI

$20.96 - $34.61/hr

Assists nurse care manager with transitions of care including monitoring utilization reports and conducting patient outreach when appropriate.Develops strong relationships with patient care team to ...

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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 Rhode Island?

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

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

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

What cities in Rhode Island are hiring for Utilization Care Manager jobs?

Cities in Rhode Island with the most Utilization Care Manager job openings:

Utilization Care Manager jobs near you

Nurse Care Manager

East Bay Community Action Program

Newport, RI • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 2 days ago

Job description

Nurse Care Manager
Department: Medical
Employment Type: Full Time
Location: Newport - Chafee Medical
Reporting To: Director of Nursing
Description
The Nurse RN Care Manager provides comprehensive clinical care management, chronic disease support, transitional care coordination, patient education, and whole-person care planning for high-risk and medically complex patients across medical and behavioral health services. This role supports Patient-Centered Medical Home (PCMH) standards, value-based care initiatives, Accountable Entity (AE) requirements, CCBHC integration, and organizational quality goals through interdisciplinary collaboration, proactive outreach, and population health management.
What You'll Do
Lead High-Impact Care Management
  • Identify and prioritize high-risk, high-utilizing patients using population health tools and data to target interventions that reduce preventable hospitalizations and emergency visits.
  • Develop and manage individualized care plans with clear goals, evidence-based interventions, and structured follow-up tailored to each patient's needs.
  • Manage patient panels by closing preventive and chronic care gaps while improving performance on quality and value-based care measures.

Drive Care Coordination & Transitions
  • Lead transitional care management, ensuring smooth hospital-to-home transitions through timely outreach, medication reconciliation, and follow-up care.
  • Partner with primary care, behavioral health, and interdisciplinary teams to deliver coordinated, integrated care.
  • Facilitate case conferences and treatment planning to support shared patients and optimize outcomes.

Engage Patients & Address Whole-Person Needs
  • Proactively engage patients through outreach and coaching strategies that improve adherence, self-management, and health literacy.
  • Address social determinants of health by connecting patients to internal and community-based resources that remove barriers to care.
  • Use motivational interviewing and culturally responsive communication to build trust and drive meaningful behavior change.

Strengthen Quality, Compliance & Outcomes
  • Conduct ongoing assessments and adjust care plans based on patient condition, risk, and utilization patterns.
  • Monitor hospital utilization trends and implement targeted interventions to reduce avoidable admissions.
  • Ensure accurate, compliant documentation that supports quality reporting, regulatory requirements, and value-based care initiatives such as MSSP and payer contracts.

Collaborate & Contribute Across the Organization
  • Serve as a key liaison across providers, community partners, and programs to ensure seamless, integrated service delivery.
  • Participate in interdisciplinary meetings and organizational initiatives to improve population health and patient experience.
  • Provide clinical support, including direct RN functions as needed, to ensure continuity and excellence in care delivery.

This is a dynamic, patient-centered role where you'll combine clinical expertise, data-driven decision-making, and strong collaboration to make a measurable impact on both individual patients and broader populations.
Required Credentials & Experience
• A minimum of an Associate's Degree in Nursing.
• Active Registered Nurse (RN) licensure in the State of Rhode Island.
• Minimum of two (2) years of experience in community health, primary care, acute care, or care management involving coordination of complex patient needs.
• Demonstrated experience managing high-risk or medically complex patient populations and coordinating interdisciplinary care.
Core Competencies
• Demonstrates strong clinical judgment and prioritization skills to manage complex patient needs in a fast-paced environment.
• Applies accountability and data-driven decision-making to achieve measurable outcomes in population health and quality performance.
• Builds effective partnerships across interdisciplinary teams and external organizations to coordinate comprehensive care.
• Communicates clearly and effectively with diverse patient populations, adapting approach to support understanding and engagement.
• Maintains high standards of organization, documentation accuracy, and follow-through on care plans and patient needs.
• Shows adaptability and resilience in managing changing priorities, patient needs, and organizational requirements.
Preferred Qualifications
• Experience working within a Patient-Centered Medical Home (PCMH) or value-based care environment.
• Familiarity with Accountable Entity programs, MSSP, or other payer-based quality initiatives.
• Knowledge of population health tools and electronic health record (EHR) systems used for care management and reporting.
Benefits
For Full-Time Employees Working 30-40 hours per week, EBCAP offers:
  • Subsidized, comprehensive medical (BCBSRI) and dental (Delta Dental) insurance plans
  • Supplemental vision insurance (Delta Dental)
  • Voluntary medical and dependent care flexible spending accounts
  • Up to 3% matching 403(b) retirement plan
  • Employer-paid life insurance
  • Generous paid time off including vacation, holidays, personal days, and sick time
  • Mileage reimbursement
  • Tuition reimbursement
  • Employer-paid professional development
  • Employee assistance program

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