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Utilization Case Manager Jobs in Ashburn, VA (NOW HIRING)

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

Aldie, VA

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

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 ...

Encompass Health

Case Manager II

Aldie, VA

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

GQR

RN - Case Manager

Falls Church, VA

$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 ...

Inova

Registered Nurse (RN) Case Manager

Fairfax, VA

The RN Case Manager 1 provides discharge planning and continuity of care for assigned patients in ... Uses utilization management techniques to determine the medical necessity, appropriateness and ...

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Utilization Case Manager information

See Ashburn, VA salary details

$16

$37

$61

How much do utilization case manager jobs pay per hour?

As of May 28, 2026, the average hourly pay for utilization case manager in Ashburn, VA is $37.31, according to ZipRecruiter salary data. Most workers in this role earn between $30.24 and $39.33 per hour, depending on experience, location, and employer.

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 Ashburn, VA? For Utilization Case Manager jobs in Ashburn, VA, the most frequently searched job titles are:
What job categories do people searching Utilization Case Manager jobs in Ashburn, VA look for? The top searched job categories for Utilization Case Manager jobs in Ashburn, VA are:
What cities near Ashburn, VA are hiring for Utilization Case Manager jobs? Cities near Ashburn, VA with the most Utilization Case Manager job openings:
Utilization Case Manager jobs near you
Infographic showing various Utilization Case Manager job openings in Ashburn, VA as of May 2026, with employment types broken down into 2% As Needed, 75% Full Time, 17% Part Time, 3% Temporary, and 3% Contract. Highlights an 68% Physical, 6% Hybrid, and 26% Remote job distribution, with an average salary of $77,607 per year, or $37.3 per hour.
RN Utilization Management

RN Utilization Management

MedStar Health

Washington, DC • On-site

$89.07K - $162.80K/yr

Full-time

Posted 3 days ago

Medstar Health rating

7.7

Company rating: 7.7 out of 10

Based on 237 frontline employees who took The Breakroom Quiz

158th of 864 rated healthcare providers

Job description

About the Job
General Summary of Position
Responsible for evaluating the necessity appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of acute care services based on Medically Necessity criteria the management of quality health care resources for achievement of desired outcomes and coordination of alternative levels of care in a timely and in the most cost-effective manner.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.
Primary Duties and Responsibilities
  • Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Acts as a liaison to MedStar Family Choice (MFC) contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
  • Acts as an advocate while assisting members to coordinate and gain access to medical psychiatric psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
  • Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups etc. as assigned. Provides input completes assignments and shares new findings with other staff. Participates in meetings and on committees and represents the department and MFC in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
  • Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
  • Demonstrates skill and flexibility in providing coverage for other staff.
  • Identifies inpatients requiring additional services and initiates care with appropriate providers. Demonstrates emphasis on quality patient care during the pre-admission and/or concurrent review process. Authorizes services according to MedStar Family Choice policy.
  • Initiates contact with providers to obtain clinical information to facilitate approval or pending of pre-authorization requests inpatient stays and retrospective reviews.
  • Maintains current knowledge of MFC benefits and enrollment issues in order to accurately coordinate services.
  • Maintains timely and accurate documentation in the clinical software system per Clinical Operations department's policy.
  • Monitors utilization of all services for fraud and abuse.
  • Performs pre-authorization and pharmacy reviews and documents in PBM's system when assigned.
  • Performs telephonic ACD line coverage for Clinical Operations' needs.
  • Performs telephonic inpatient utilization review services; on-site review as indicated. Process includes: assessment planning coordinating and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning as applicable.
  • Makes referrals to Case Management as needed.
  • Sends thorough reviews to Medical Director as appropriate. Coordinates timely review decisions and notifications per policy NCQA standards/guidelines and District of Columbia Contract.
  • Utilizes evidence-based standards in making coverage determinations in individual patient cases; Identifies and reports potential coordination of benefits subrogation third party liability worker's compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.

Minimal Qualifications
Education
  • Valid RN license in the District of Columbia; or Maryland required and
  • Bachelor's degree preferred

Experience
  • 1-2 years Recent utilization experience required and
  • 1-2 years Diverse clinical experience required

Licenses and Certifications
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia; or Maryland Upon Hire required and
  • CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred

Knowledge Skills and Abilities
  • Proficient computer skills to enter and retrieve data.
  • Ability to create edit and analyze Microsoft office (Word Excel and PowerPoint) preferred.
  • Knowledge of InterQual guidelines preferred.

This position has a hiring range of
USD $89,065.00 - USD $162,801.00 /Yr.

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About Medstar Health

Sourced by ZipRecruiter

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Columbia, MD, US

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