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Utilization Case Manager Jobs (NOW HIRING)

BronxCare Health System

Assistant Director

Bronx, NY

Assists the Director to administer operations and activities of the Utilization Case Management Department in support of policies, goals and objectives established by the Hospital by providing direct ...

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How much do utilization case manager jobs pay per hour?

As of May 31, 2026, the average hourly pay for utilization case manager in the United States is $36.49, according to ZipRecruiter salary data. Most workers in this role earn between $29.57 and $38.46 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.

More about Utilization Case Manager jobs
What cities are hiring for Utilization Case Manager jobs? Cities with the most Utilization Case Manager job openings:
What states have the most Utilization Case Manager jobs? States with the most job openings for Utilization Case Manager jobs include:
What job categories do people searching Utilization Case Manager jobs look for? The top searched job categories for Utilization Case Manager jobs are:
Utilization Case Manager jobs near you
Infographic showing various Utilization Case Manager job openings in the United States as of May 2026, with employment types broken down into 2% As Needed, 74% Full Time, 18% Part Time, 3% Temporary, and 3% Contract. Highlights an 37% Physical, 11% Hybrid, and 52% Remote job distribution, with an average salary of $75,891 per year, or $36.5 per hour.
Experienced Case Manager - RN PRN Premium

Experienced Case Manager - RN PRN Premium

Franciscan Missionaries of Our Lady Health System

Jackson, MS • On-site

Other

Posted 15 days ago

Franciscan Missionaries of Our Lady Health System rating

7.0

Company rating: 7.0 out of 10

Based on 37 frontline employees who took The Breakroom Quiz

401st of 864 rated healthcare providers

Job description

Job Description
The Case Manager 1 directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas. Relies on education, experience, professional training and judgment to accomplish responsibilities. A wide degree of creativity and latitude is expected. Works under minimal supervision. Directs the utilization review of patient charts and treatment plans pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager of Clinical Services specializes in the review of information pertaining specifically to the assigned area (i.e.: Case Management, Geriatrics, Mental & Behavioral Health, Home Health). Most, but not all, of the accountabilities below may apply to each specific area.
Responsibilities
  1. Evaluation and Analysis:
    1. Contributes to cost effectiveness/efficiency and demonstrates awareness of benefit system and cost benefit analysis. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring, and analysis of annual financial goals of targeted population.
    2. Understands the capabilities of outside referral sources such as home health, sub-acute care and skilled nursing facilities. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures, and continued stay.
    3. Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is the most appropriate.
  2. Partnership and Collaboration
    1. Performs effective utilization review techniques to work with physicians, third party payors, and federal and local agencies to prevent denials of payment or days.
    2. Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
    3. Collaborates with all members of the health team to ensure reimbursement optimization, appropriate discharge planning, and cost-effective quality care. Plays a key role in the discharge planning process assessing patient's needs for referrals and/or alternate levels of care. Appropriately tracks and reports avoidable days.
    4. Demonstrates competence in coordination and service delivery. Understands methods for assessing an individual's level of physical/mental impairment. Assesses patient clinical information and in collaboration with the healthcare team, develops treatment/discharge plans.
  3. Quality
    1. Evaluates the quality of necessary medical services, utilizes criteria to determine medical necessity of admission and interacts with physicians to facilitate patient assignment to appropriate alternative of care.
    2. Provides appropriate and timely information to third party payors to facilitate financial outcomes and ensures patients are receiving appropriate level of care; includes coordinating denials/appeals.
    3. Demonstrates ability to access and utilize community resources. Is knowledgeable of the ADA and other federal legislation affecting individuals with disabilities. Knows how to establish a client support system.
    4. Observes and adheres to all departmental and hospital policies and procedures, and follows all safety, quality assurance, and infection control standards.
    5. Promotes the quality and efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job-relevant seminars and workshops, attendance at professional conferences, and affiliations with national and state professional organizations.
  4. Other Duties as Assigned
    1. Performs other duties as assigned or requested.

Qualifications
Experience - Three years in general or specialty nursing practice
Education - Associate's Degree
Licensure - Current and unrestricted Mississippi State License as RN

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About Franciscan Missionaries of Our Lady Health System

Sourced by ZipRecruiter

The Franciscan Missionaries of Our Lady Health System is the leading health care innovator in Louisiana. We bring together outstanding clinicians, the most advanced technology and leading research to ensure that our patients receive the highest quality and safest care possible.

Industry

Hospitals

Company size

5,001 - 10,000 Employees

Headquarters location

Baton Rouge, LA, US

Year founded

1911

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