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Utilization Management Representative Jobs in New York

Medix

Director of Utilization Management

Manhattan, NY · On-site

$109.15 - $151.44/hr

The actual posting represents a position at one of our clients. Job Summary Our client is seeking a skilled Director of Utilization Management to oversee the delivery of utilization management ...

Tandym Group

Managed Care Coordinator

Manhattan, NY · On-site

... service representative, or case management assistant * Managed care, care coordination, care management, or utilization management experience * Experience with authorizations, provider or vendor ...

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All JobsUtilization Management Representative JobsUtilization Management Representative Jobs in New York

Utilization Management Representative information

See New York salary details

$26.8K

$48.4K

$84.2K

How much do utilization management representative jobs pay per year?

As of Aug 28, 2026, the average yearly pay for utilization management representative in New York is $48,377.00, according to ZipRecruiter salary data. Most workers in this role earn between $41,000.00 and $47,000.00 per year, depending on experience, location, and employer.

What is a utilization management representative?

Utilization Management Representatives are professionals who review and evaluate medical services to ensure that patients receive appropriate care while managing healthcare costs. They work for insurance companies, healthcare providers, or third-party administrators, and their primary role is to assess the necessity, efficiency, and appropriateness of medical treatments and procedures. They communicate with healthcare providers, review clinical information, and make coverage determinations based on established guidelines. Their work helps balance quality patient care with cost-effective use of healthcare resources.

What are the key skills and qualifications needed to thrive as a utilization management representative?

To thrive as a Utilization Management Representative, you need a solid understanding of healthcare policies, insurance procedures, and medical terminology, often supported by a background in healthcare administration or a related field. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Strong attention to detail, effective communication, and problem-solving skills help professionals excel when interacting with healthcare providers and patients. These skills ensure accurate review of medical necessity, timely authorization of services, and regulatory compliance, all of which are critical for efficient healthcare delivery.

What are some common challenges utilization management representatives face when coordinating care with healthcare providers?

Utilization Management Representatives often encounter challenges such as navigating differing opinions between healthcare providers and insurance guidelines, handling high caseloads, and ensuring timely communication among all parties. They must balance advocating for patient care with adhering to coverage policies, which can sometimes require negotiation and problem-solving skills. Staying organized and keeping up with regulatory changes are also important to effectively manage these complexities and provide quality support to both patients and providers.

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

AspectUtilization Management RepresentativeUtilization Review Coordinator
CertificationsTypically requires certifications like CCM or CUCOften requires similar certifications, such as CCM or RHIT
Work EnvironmentWorks in insurance companies, healthcare providers, or managed care organizationsWorks in hospitals, clinics, or insurance settings
Job FocusEvaluates medical necessity and authorizes servicesCoordinates review processes and communicates with providers

Both roles involve reviewing healthcare services, but the Utilization Management Representative primarily assesses medical necessity and authorizes care, while the Utilization Review Coordinator manages the review process and liaises with providers. They share similar certifications and work environments, making them closely related in the healthcare utilization management field.

What are popular job titles related to Utilization Management Representative jobs in New York?

For Utilization Management Representative jobs in New York, the most frequently searched job titles are:

What job categories do people searching Utilization Management Representative jobs in New York look for?

The top searched job categories for Utilization Management Representative jobs in New York are:

Utilization Management Representative jobs near you
Infographic showing various Utilization Management Representative job openings in New York as of August 2026, with employment types broken down into 86% Full Time, and 14% Part Time. Highlights an 93% In-person, and 7% Remote job distribution, with an average salary of $48,377 per year, or $23.3 per hour.

Utilization Management Nurse Consultant

CVS Health

New York, NY • Remote

$32.01 - $68.55/hr

Full-time

Medical, Dental, Vision, Retirement, PTO

Re-posted 6 days ago

CVS Health rating

5.8

Company rating: 5.8 out of 10

Based on 4,352 frontline employees who took The Breakroom Quiz

90th of 113 rated pharmacies

Job description

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselvesaccountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Registered Nurse (RN) - Utilization Management

Join a dynamic healthcare team and make an impact on patient care from wherever you work.

We are seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will use your clinical expertise to review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services.

What You'll Do

  • Review clinical information and apply evidence-based criteria to support coverage determinations and care recommendations.
  • Collaborate with providers, care teams, and internal partners to coordinate treatment and services.
  • Identify opportunities to improve healthcare quality, outcomes, and benefit utilization.
  • Refer members to appropriate programs and services that support their overall health needs.
  • Serve as a clinical resource for utilization and benefit management questions.

What We're Looking For

Required Qualifications

  • Active, unrestricted RN license in your state of residence.
  • 2+ years of RN experience in an adult acute care or critical care setting.
  • Associate Degree in Nursing.
  • Strong communication, multitasking, and computer navigation skills.
  • Ability to work a designated schedule of 8:00 am to 5:00 PM ET, including weekends, holidays, and evening hours based on business needs.

Preferred Qualifications

  • BSN preferred.
  • Clinical experience in Med-Surg or a specialty area.
  • Managed Care and/or Utilization Management experience.
  • Candidates located in the Eastern Time Zone preferred.

Why Join Us?

  • Apply your clinical expertise in a collaborative, fast-paced environment.
  • Help improve healthcare outcomes for members across the continuum of care.
  • Work with a mission-driven team focused on quality, efficiency, and patient-centered care.

Ready to leverage your nursing experience in a rewarding Utilization Management role? Apply today.

Work from Home Requirements:

  • You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
  • A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
  • Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
  • The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
  • If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:

  • Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
  • Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
  • Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
  • Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
  • Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
  • Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$32.01 - $68.55

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This fulltime position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial wellbeing of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.


Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 08/22/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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