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Utilization Case Manager Jobs in Delaware (NOW HIRING)

Encompass Health Rehabilitation Hospital of Middletown

$34.61 - $62/hr

The Certified Case Manager (CCM) serves as a key member of the interdisciplinary team and actively manages and directs resource utilization to achieve the highest quality outcomes during a patient ...

Encompass Health

Certified Case Manager

Middletown, DE · On-site

The Certified Case Manager (CCM) serves as a key member of the interdisciplinary team and actively manages and directs resource utilization to achieve the highest quality outcomes during a patient ...

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Utilization Case Manager information

What is a utilization case manager?

A Utilization Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient cases, coordinate with healthcare providers, and ensure that treatments are in line with established guidelines and insurance requirements. Their goal is to optimize patient outcomes while managing costs and ensuring compliance with regulations. Utilization Case Managers often work in hospitals, insurance companies, or managed care organizations.

What are the key skills and qualifications needed to thrive as a utilization case manager?

To thrive as a Utilization Case Manager, you need a background in nursing or social work, strong analytical skills, and a solid understanding of healthcare regulations and insurance processes, often supported by RN licensure or certification in case management (e.g., CCM). Familiarity with utilization management software, electronic health records (EHRs), and payer authorization systems is essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration among patients, providers, and payers. These skills ensure appropriate care delivery, cost management, and compliance with healthcare standards.

How does a utilization case manager typically collaborate with healthcare providers and insurance companies?

Utilization Case Managers play a key role in coordinating care between healthcare providers and insurance companies. They review patient cases to ensure that the recommended treatments are medically necessary and align with insurance policies. This often involves regular communication with doctors, nurses, and insurance representatives to gather information, clarify treatment plans, and advocate for appropriate patient care. Strong collaboration skills are essential, as Utilization Case Managers must balance the needs of patients with organizational guidelines while maintaining positive professional relationships.

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

AspectUtilization Case ManagerUtilization Review Nurse
CredentialsRN license, case management certificationRN license, certification in utilization review
Work EnvironmentCase management teams, hospitals, insurance companiesUtilization review departments, hospitals, insurance providers
Primary FocusCoordinating patient care, discharge planning, resource allocationAssessing medical necessity, reviewing patient records for appropriateness
Common UsageBroader case management roles, patient advocacySpecific review of medical necessity and insurance claims

While both roles require RN licensure and focus on patient care, the Utilization Case Manager primarily coordinates overall patient services and discharge planning, whereas the Utilization Review Nurse concentrates on evaluating the medical necessity of treatments for insurance purposes. Understanding these distinctions helps in choosing the right career path or job search focus.

What degree do I need for utilization case manager?

Utilization case managers typically need at least a bachelor's degree in healthcare, social work, nursing, or a related field. Some positions may prefer or require a master's degree or relevant certifications, such as Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ).

What job categories do people searching Utilization Case Manager jobs in Delaware look for?

The top searched job categories for Utilization Case Manager jobs in Delaware are:

What cities in Delaware are hiring for Utilization Case Manager jobs?

Cities in Delaware with the most Utilization Case Manager job openings:

Utilization Case Manager jobs near you

Case Management RN

Nemours Children's Health

Wilmington, DE • On-site

Full-time

Re-posted 6 days ago

Nemours Children's Health rating

8.1

Company rating: 8.1 out of 10

Based on 87 frontline employees who took The Breakroom Quiz

66th of 898 rated healthcare providers

Job description


Nemours is hiring a Nurse Case Manager. The Nurse Case Manager (NCM)/Case Management RN is responsible for the coordination of care of individual patients in the Inpatient and Emergency Department acute care environment. Through the use of the nursing process, patient care will be assessed, planned, implemented and evaluated with consideration to the appropriate use of resources, anticipatory discharge and timely progression of care. The NCM will manage care with a focus on designated clinical, operational, and financial outcomes for aggregate patient populations. In collaboration with the interdisciplinary team and a family-centered process, the NCM will work to improve outcomes as measured by timely discharge from acute inpatient care, connection to post-discharge care/appointments, family/caregiver access to needed supplies, reduced readmission rates, and improved patient/family satisfaction. Discharge planning, transitions of care and outpatient care of patients within the continuum of care will be aligned with:
  • American Case Management Association Standards of Practice and Scope of Services (ACMA)
  • American Case Management Association Transitions of Care (ACMA)
  • Case Management Society of America Standards of Practice (CMSA)

The NCM is accountable for adherence to policies and procedures of Nemours Children's Hospital, Delaware, and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care.
The NCM is expected to maintain all state and federal clearances for DE.
Qualifications:
  • Diploma/AD required; BSN preferred
  • Active Registered Nurse license in the applicable state(s) (required)
  • Case management or utilization management certification (preferred)
  • Minimum of five (5) years of progressive clinical experience, including utilization management, case management, or related healthcare operations

Primary Responsibilities:
  1. Assesses inpatient and Emergency Department patients for discharge planning needs, social drivers of health, gaps in care, and access to post-acute services and supplies (e.g., DME, home nursing).
  2. Collaborates with providers, social work, and the interdisciplinary team to develop and implement patient-centered plans of care and discharge plans, with a clear timeline and estimated discharge date.
  3. Monitors clinical progression and barriers to discharge; escalates issues to support appropriate level of care, length of stay, and resource utilization.
  4. Partners with Utilization Management to support medical necessity and correct patient status (inpatient vs. observation/OPER); supports denial prevention and appeals through timely, complete clinical documentation, educating providers around medical necessity/denials, and support for peer to peer reviews.
  5. Identifies patients at risk for unsafe transitions, high ED utilization, or readmission; completes transition assessments and coordinates follow-up care and appointments.
  6. Communicates with patients/families and the care team to address barriers, coordinate services, and adapt plans based on changes in clinical status or goals of care.
  7. Provides patient/family education on the discharge process, including follow-up needs, and medications/supplies; confirms understanding and documents education as appropriate.
  8. Initiates and coordinates referrals to internal and community resources to support discharge needs (e.g., home health, DME, transportation, pharmacy). Ensure timely and accurate delivery and fulfillment of discharge resources.
  9. Coordinates transitions of care with outside hospital/facility case management and care coordination teams, including discharge to home, transfer to another acute care facility, home services, or skilled nursing facility

About Us
Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.
Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.
Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.
Learn more at Nemours.org.

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About Nemours

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As one of the nation's leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics, primary care practices, and school-based health centers in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children - even those who may never enter our doors - through our world-changing research, education and advocacy efforts.

Industry

Health care and social assistance and hospitals

Company size

1,001 - 5,000 Employees

Headquarters location

Jacksonville, FL, US

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