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Utilization Management Associate Jobs in Pennsylvania

WellSpan Health

Care Management Nurse

Ephrata, PA · On-site

Associates Degree Required Work Experience: * 2 years Recent acute care experience. Required * Utilization management, care management, or clinical nursing specialty. Preferred * Previous experience ...

Integrated Resources

Clinical Care RN

Harrisburg, PA · On-site

Works with the Utilization Management Manager, the Medical Director and providers to ensure that ... Associates RN degree required, Bachelor's degree preferred. Experience: RN must have two - 3 years ...

IRMC

RN Care Manager - Casual

Indiana, PA · On-site

... utilization of resources and cost through ongoing case management and communication with all ... Diploma Program, Associate's, or Bachelor's Degree in Nursing or other health-related field

Socket.dev

RN Care Manager - Casual

Indiana, PA · On-site

... utilization of resources and cost through ongoing case management and communication with all ... Diploma Program, Associate's, or Bachelor's Degree in Nursing or other health-related field

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Utilization Management Associate information

What does a utilization management associate do?

A Utilization Management Associate is responsible for reviewing healthcare services and determining whether they are medically necessary, appropriate, and efficient. They work with healthcare providers, insurance companies, and patients to ensure that treatments comply with established guidelines and policies. Their role often includes reviewing medical records, processing authorizations, and assisting in the coordination of care to optimize the use of healthcare resources. This position helps control costs while ensuring that patients receive the appropriate level of care.

What skills and qualifications are needed to thrive as a utilization management associate?

A Utilization Management Associate typically needs a background in healthcare administration or a related field, strong analytical skills, and knowledge of medical terminology and insurance guidelines. Familiarity with utilization review software, electronic health records (EHRs), and regulatory compliance systems is important, and certifications like Certified Professional in Healthcare Management (CPHM) can be advantageous. Attention to detail, effective communication, and strong organizational skills help associates excel in evaluating medical necessity and collaborating with care teams. These competencies ensure accurate, efficient review processes that support quality patient care and compliance with payer requirements.

What are the typical daily responsibilities of a utilization management associate?

Utilization Management Associates typically review medical records, verify insurance coverage, and coordinate with healthcare providers to ensure that treatments and services meet established guidelines and payer requirements. They also communicate with physicians and patients to gather necessary information for authorization requests. By ensuring appropriate utilization of healthcare resources, they help support patient care while managing costs and compliance for their organization. Collaboration with clinical staff and insurance representatives is a key part of the role, contributing to effective case management.

What is the difference between Utilization Management Associate vs Utilization Review Coordinator?

AspectUtilization Management AssociateUtilization Review Coordinator
CertificationsTypically requires a healthcare-related certification or licenseOften requires similar certifications, such as CCM or RHIA
Work EnvironmentWorks in insurance companies, healthcare providers, or managed care organizationsWorks in hospitals, insurance companies, or healthcare facilities
Job FocusAssists in reviewing medical necessity and authorization processesCoordinates and conducts utilization reviews and approvals
Common UsageUsed interchangeably in healthcare and insurance settingsOften used in hospital and insurance contexts

The Utilization Management Associate and Utilization Review Coordinator roles share similarities in certifications and work environments, focusing on reviewing medical necessity and authorization. The main difference lies in their specific responsibilities, with associates assisting in the process and coordinators actively conducting reviews and approvals.

What are the most commonly searched types of Utilization Management jobs in Pennsylvania?

The most popular types of Utilization Management jobs in Pennsylvania are:

What cities in Pennsylvania are hiring for Utilization Management Associate jobs?

Cities in Pennsylvania with the most Utilization Management Associate job openings:

Infographic showing various Utilization Management Associate job openings in Pennsylvania as of August 2026, with employment types broken down into 1% As Needed, 87% Full Time, 10% Part Time, and 2% Contract. Highlights an 82% Physical, 3% Hybrid, and 15% Remote job distribution.

Care Management Nurse

Ephrata, PA • On-site

WellSpan Health
Hospitality Services • 10K+ employees
Learn more about WellSpan Healthexternal

Part-time

Medical, Retirement, PTO

Re-posted 4 days ago

WellSpan Health rating

7.6

Company rating: 7.6 out of 10

Based on 307 frontline employees who took The Breakroom Quiz

Job description

8:30am to 9:00pm

Shifts primarily covering the Emergency Departments but also flexing to in house units based upon department needs

Weekend and holiday rotations required

Previous experience in care management, discharge planning, previous nursing experience in ED, critical care, trauma, step down units, medical, surgical, geriatrics are all strongly preferred

General Summary

Performs a variety of duties and applies utilization and care management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Works in a team type assignment or Care Coordination Team (CCT) Model (Care Manager and Social Worker teams are assigned to patients by physician practice) to address patient care transition needs. Provides leadership in the integration of utilization and care management principles throughout the hospital.

WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.
WellSpan Ephrata Community Hospital

One of eight premier hospitals in the WellSpan system, WellSpan Ephrata Community Hospital offers a full range of leading-edge inpatient, outpatient and emergent care services. The hospital is noted for its distinct ability to combine state-of-the-art medical technology with quality, compassionate care to meet the needs of the more than 550,000 residents of northern Lancaster County and the surrounding area. As a full-service, non-profit acute-care hospital, with a 141 licensed bed capacity, WellSpan Ephrata Community Hospital admits approximately 5,500 patients annually. Nearby WellSpan Ephrata Cancer Center supports the hospital as part of WellSpan's regional network of five cancer centers. WellSpan Ephrata Community Hospital was one of several WellSpan Health hospitals honored by U.S. News & World Report with the High Performing recognition for 2022-23.

Qualifications
Minimum Education:

  • Associates Degree Required

Work Experience:

  • 2 years Recent acute care experience. Required
  • Utilization management, care management, or clinical nursing specialty. Preferred
  • Previous experience in care management, discharge planning, previous nursing experience in ED, critical care, trauma, step down units, medical, surgical, geriatrics are all strongly preferred

Licenses:

  • Licensed Registered Nurse Upon Hire Required or
  • Registered Nurse Multi State License Upon Hire Required and
  • Basic Life Support Upon Hire Required

Knowledge, Skills, and Abilities:

  • Excellent interpersonal/communication skills.

Benefits Offered:

  • Comprehensive health benefits
  • Retirement savings plan
  • Paid time off (PTO)
  • Education assistance
  • Financial education and support, including DailyPay
  • Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)

Duties and Responsibilities

  • Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
  • Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization.
  • Liaisons between third party payers and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
  • Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.
  • Identifies conditions which require care management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs.
  • Makes arrangements for discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families and care team as needed.
  • Assists with the collection and analysis of utilization patterns and denied cases.
  • Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).

Common Expectations:

  • Prepares and maintains appropriate documentation as required.
  • Maintains established policies and procedures, objectives, quality assessment and safety standards.
  • Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

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