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Utilization Review Case Manager Jobs in Delaware

Encompass Health

Certified Case Manager

Middletown, DE · On-site

The Certified Case Manager (CCM) serves as a key member of the interdisciplinary team and actively ... The CCM performs ongoing utilization review and acts as a liaison to the payor while assuring that ...

Encompass Health

Certified Case Manager

Middletown, DE · On-site

The Certified Case Manager (CCM) serves as a key member of the interdisciplinary team and actively ... The CCM performs ongoing utilization review and acts as a liaison to the payor while assuring that ...

Encompass Health Rehabilitation Hospital of Middletown

$34.61 - $62/hr

The Certified Case Manager (CCM) serves as a key member of the interdisciplinary team and actively ... The CCM performs ongoing utilization review and acts as a liaison to the payor while assuring that ...

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Utilization Review Case Manager information

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$16

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$60

How much do utilization review case manager jobs pay per hour?

As of Sep 1, 2026, the average hourly pay for utilization review case manager in Delaware is $36.52, according to ZipRecruiter salary data. Most workers in this role earn between $29.62 and $38.51 per hour, depending on experience, location, and employer.

What is a utilization review case manager?

A Utilization Review Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical treatments and services provided to patients. They review clinical information, coordinate with providers and insurance companies, and ensure that patient care aligns with established guidelines and policies. Their goal is to optimize patient outcomes while managing healthcare costs and ensuring compliance with regulations.

What are some common challenges utilization review case managers face when coordinating care across multiple departments?

Utilization Review Case Managers often navigate complex communication between physicians, nursing staff, insurance providers, and patients to ensure appropriate care and resource use. Balancing timely authorizations with evolving patient needs and varying documentation standards can be challenging. Additionally, staying current with changing regulations and payer requirements requires ongoing learning and adaptability. Building strong collaborative relationships and maintaining clear, concise documentation are key strategies for overcoming these hurdles.

What are the key skills and qualifications needed to thrive as a utilization review case manager, and why are they important?

To thrive as a Utilization Review Case Manager, you need a clinical background such as an RN or LCSW license, strong knowledge of medical necessity criteria, and experience with case management. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of regulatory guidelines like Medicare and Medicaid are essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration between patients, providers, and payers. These skills ensure appropriate resource use, compliance with regulations, and high-quality patient care.

What is the difference between Utilization Review Case Manager vs Utilization Review Nurse?

AspectUtilization Review Case ManagerUtilization Review Nurse
CredentialsTypically requires a nursing license or relevant healthcare certificationRegistered Nurse (RN) license is required
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinic, insurance review departments
Primary FocusReviewing medical necessity, coordinating care, managing casesAssessing medical records, clinical review, patient care evaluation

Both roles involve healthcare review and require nursing credentials, but the Utilization Review Case Manager often focuses on coordinating care and managing cases, while the Utilization Review Nurse emphasizes clinical assessment and review of medical records. Understanding these differences helps in choosing the right career path or job search focus.

What are popular job titles related to Utilization Review Case Manager jobs in Delaware?

For Utilization Review Case Manager jobs in Delaware, the most frequently searched job titles are:

What job categories do people searching Utilization Review Case Manager jobs in Delaware look for?

The top searched job categories for Utilization Review Case Manager jobs in Delaware are:

What cities in Delaware are hiring for Utilization Review Case Manager jobs?

Cities in Delaware with the most Utilization Review Case Manager job openings:

Utilization Review Case Manager jobs near you
Infographic showing various Utilization Review Case Manager job openings in Delaware as of August 2026, with employment types broken down into 57% Full Time, and 43% Contract. Highlights an 100% In-person job distribution, with an average salary of $75,956 per year, or $36.5 per hour.

Utilization Management Specialist I

SUN Behavioral Delaware

Georgetown, DE • On-site

Full-time

Posted 17 days ago

Sun Behavioral Health rating

6.2

Company rating: 6.2 out of 10

Based on 10 frontline employees who took The Breakroom Quiz

Job description

Position Summary:
Responsible for the coordination of case management strategies pursuant to the Case Management process. Assists and coordinates care of the patient from pre-hospitalization through discharges. Responsible for assisting with authorization of admissions to hospital. Processes retroactive reviews and appeals, copies needed documentation and writes retro/appeal letters for insurance companies to ensure coverage for patient admissions. Conducts follow up calls with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department.
Position Responsibilities:
Clinical / Technical Skills (40% of performance review)
  • Provides thorough documentation and timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews and discharges; including case s with limited benefits, cases in peer review/denial and /or unplanned discharges
  • Coordinates with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Document s and updates the denial log to reflect same.
  • Consults Business Office and/or admission staff as needed to clarify data and ensure authorization processes are complete.
  • Documents in HCS the results of admission and concurrent reviews.
  • Stays informed about changes in Medicare and Medicaid.
  • Ability to stage local laws, ordinances and practices governing involuntary hospitalization and ensure compliance with same.
  • Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment.
  • Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Oversees continuity of care for each level of care transition.
  • Develops and maintains processes to minimize denials and communication of same to CFO and Business Office Director.
  • Reports results of daily treatment team meetings all discharges and status of high-risk case such as limited benefits, peer reviews, denials or unplanned discharges.
  • Timely retroactive reviews and appeals within current month
  • Strong knowledge of external review organizations (i.e.: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
  • Types and mails all correspondence in a timely manner.
  • Answers the telephone in a polite manner, Communicates information to the appropriate staff.
  • Interacts with patients/families in a professional manner. Provides explanations regarding statements, insurance coverage.
  • Support discharge planning and utilization review when necessary
  • Perform other duties as required

Safety (15% of performance review)
  • Strives to create a safe, healing environment for patients and family members
  • Follows all safety rules while on the job.
  • Reports near misses, as well as errors and accidents promptly.
  • Corrects minor safety hazards.
  • Communicates with peers and management regarding any hazards identified in the workplace.
  • Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
  • Participates in quality projects, as assigned, and supports quality initiatives.
  • Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)
  • Works well with others in a spirit of teamwork and cooperation.
  • Responds willingly to colleagues and serves as an active part of the hospital team.
  • Builds collaborative relationships with patients, families, staff, and physicians.
  • The ability to retrieve, communicate, and present data and information both verbally and in writing as required
  • Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
  • Demonstrates adequate skills in all forms of communication.
  • Adheres to the Standards of Behavior

Integrity (15% of performance review)
  • Strives to always do the right thing for the patient, coworkers, and the hospital
  • Adheres to established standards, policies, procedures, protocols, and laws.
  • Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
  • Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
  • Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership
  • Exemplifies professionalism through good attendance and positive attitude, at all times.
  • Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
  • Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)
  • Demonstrates accountability for ensuring the highest quality patient care for patients.
  • Willingness to be accepting of those in need, and to extend a helping hand
  • Desire to go above and beyond for others
  • Understanding and accepting of cultural diversity and differences

Education
  • Required: High school diploma or GED. CPR and hospital-selected de-escalation technique certification.
  • Preferred: Associates or Bachelors degree.
  • Maintains education and development appropriate for position.
  • May substitute experience for education

Experience
  • Required: One year of experience in a behavioral healthcare setting.
  • Preferred: Previous experience in a Utilization Management department or as a Mental Health Tech
  • May substitute education for experience

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