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Utilization Care Manager Jobs in Rhode Island (NOW HIRING)

Gbmc

$66K - $102K/yr

Plans and supervises the delivery of care by the HHA Cooperates with Clinical Manager in utilization of other team members, outside agencies, and community resources. Updates primary physician when ...

Gbmc

$66K - $102K/yr

Plans and supervises the delivery of care by the HHA Cooperates with Clinical Manager in utilization of other team members, outside agencies, and community resources. Updates primary physician when ...

Bcbsri

Case Manager - Behavioral Health

Providence, RI · On-site +1

$73K - $110K/yr

Knowledge of utilization management and/or coordination of care * Knowledge of population health ... and chronic condition management principles * Understanding of health care delivery system access ...

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All JobsUtilization Care JobsUtilization Care Manager JobsUtilization Care Manager Jobs in Rhode Island

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

Case Manager (NE)

CharterCARE of Rhode Island

North Providence, RI

Full-time

Re-posted 12 days ago

Job description

Main Function 

Reports to the Director Care Management or designee.  Provides coordinated care support to Physician leadership and Clinical Manager(s) of respective services.  Makes daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include pre-admission and post hospital discharge.  Participates in the oversight of the progress of a specific patient population.  Performs functions related to Patient Advocacy; Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality and cost effectiveness of patient care and prevent readmissions.   

Education/Experience 

Graduate of a School of Nursing (BSN preferred) with current license to practice as a Registered Nurse in the State of Rhode Island or in the nurse’s primary state of legal residency if that state is a member of the Nurse Licensure Compact.   Five (5) years of clinical experience that includes recent experience with case management, patient navigation, case management, utilization review or discharge planning is strongly preferred.   

Must exhibit strong interpersonal skills as well as a collaborative approach and style of communication in order to interact successfully on a daily basis with a wide and diverse population of both health care providers, patients and their families. 

Familiarity with InterQual™ / MCG care management criteria is required. 

Must demonstrate knowledge and skill necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process. 

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