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Utilization Case Manager Jobs in Washington (NOW HIRING)

Encompass Health

Case Manager

Bowie, MD · On-site

$19.25 - $24.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * Must be qualified to ...

MedStar Health

RN Utilization Management

Washington, DC · On-site

$89.07K - $162.80K/yr

Monitors utilization of all services for fraud and abuse. * Performs pre-authorization and pharmacy ... CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred Knowledge Skills and ...

MedStar Health

RN Utilization Mgmt

Washington, DC · On-site

$89.07K - $162.80K/yr

About the Job General Summary of Position The RN Utilization Manager will have 1-2 years of ... CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred Knowledge Skills and ...

Encompass Health

Case Manager II

Bowie, MD

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

MedStar Health

RN Case Manager

Washington, DC · On-site

Identifies quality risk or utilization issues to appropriate MedStar personnel. * Identifies ... CCM - Certified Case Manager Upon Hire preferred Knowledge Skills and Abilities * Verbal and ...

MedStar Health

RN Case Manager

Washington, DC · On-site

Identifies quality risk or utilization issues to appropriate MedStar personnel. * Identifies ... CCM - Certified Case Manager Upon Hire preferred Knowledge Skills and Abilities * Verbal and ...

MedStar Health

RN Case Manager

Washington, DC

Identifies quality risk or utilization issues to appropriate MedStar personnel. * Identifies ... CCM - Certified Case Manager Upon Hire preferred Knowledge Skills and Abilities * Verbal and ...

GQR

RN - Case Manager

Falls Church, VA · On-site

$2.51K - $2.61K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Falls Church, Virginia Start Date: April 6, 2026 Profession: Registered Nurse (RN) Facility: Short Term Acute Care ...

CVS Health

Case Manager, Registered Nurse

Washington, DC · Remote

$54.10K - $155.54K/yr

Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care ...

CVS Health

Case Manager, Registered Nurse

Washington, DC · Remote

$54.10K - $155.54K/yr

Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care ...

CVS Health

Case Manager, Registered Nurse

Annapolis, MD · Remote

$54.10K - $155.54K/yr

Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care ...

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Utilization Case Manager information

What are the key skills and qualifications needed to thrive as a Utilization Case Manager, and why are they important?

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 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 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 are popular job titles related to Utilization Case Manager jobs in Washington? For Utilization Case Manager jobs in Washington, the most frequently searched job titles are:
What job categories do people searching Utilization Case Manager jobs in Washington look for? The top searched job categories for Utilization Case Manager jobs in Washington are:
What cities in Washington are hiring for Utilization Case Manager jobs? Cities in Washington with the most Utilization Case Manager job openings:
Utilization Case Manager jobs near you
Case Manager/ Utilization Reviewer

Case Manager/ Utilization Reviewer

University of Maryland Medical System

Largo, MD • On-site

$40.61 - $60.96/hr

Full-time

Posted 1 hour ago

Job description

Job Requirements
Located in Largo in the heart of Prince George's County, our new state-of-the-art regional medical center (University of Maryland Capital Region Medical Center) will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George's County residents.
Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient's need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.
1. Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
2. Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
3. Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.
4. Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
5. Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
6. Conducts HINN discussions/Observation Education.
7. Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
8. Ensures Regulatory Compliance related to Utilization Management conditions of participation.
9. Assures appropriate reimbursement and stewardship of organizational and patient resources.
10. Pursues and reports opportunities to improve reimbursement.
11. Remains current on clinical practice and protocols impacting clinical reimbursement.
Work Experience
Licensure Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
Education Bachelors in Nursing required.
Experience One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
Two years' experience in acute care and four years clinical healthcare experience preferred. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred
Benefits
Benefits
All your information will be kept confidential according to EEO guidelines.
Compensation:
• Pay Range: $40.61-$60.96
• Other Compensation (if applicable):

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