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Utilization Review Case Manager Jobs in Reston, VA

UHS

Utilization Review Coordinator

Washington, DC · On-site

$33.60 - $50.40/hr

Informs department director of changes in managed care companies. Maintains awareness of unique ... Six months psychiatric utilization review either for hospital or external review organization ...

UHS

Utilization Review Coordinator

Washington, DC

Informs department director of changes in managed care companies. Maintains awareness of unique ... Six months psychiatric utilization review either for hospital or external review organization ...

UHS

Utilization Review Coordinator

Washington, DC · On-site

Informs department director of changes in managed care companies. Maintains awareness of unique ... Six months psychiatric utilization review either for hospital or external review organization ...

Jobtailor

Manager, Case Management

Falls Church, VA · On-site

$85 - $115/hr

Three (3) years of experience in case management or relevant nursing experience to include utilization review, discharge planning, outcomes management, transitional planning, assessment, care ...

Inova

Manager Case Management

Falls Church, VA · On-site

$174 - $762/day

Three (3) years of experience in case management or relevant nursing experience to include utilization review, discharge planning, outcomes management, transitional planning, assessment, care ...

Inova

Manager Case Management

Falls Church, VA · On-site

$21.25 - $27.50/hr

Three (3) years of experience in case management or relevant nursing experience to include utilization review, discharge planning, outcomes management, transitional planning, assessment, care ...

Encompass Health

Case Manager II

Aldie, VA · On-site

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

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

As of Aug 26, 2026, the average hourly pay for utilization review case manager in Reston, VA is $37.96, according to ZipRecruiter salary data. Most workers in this role earn between $30.77 and $40.00 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 Reston, VA?

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

What job categories do people searching Utilization Review Case Manager jobs in Reston, VA look for?

The top searched job categories for Utilization Review Case Manager jobs in Reston, VA are:

What cities near Reston, VA are hiring for Utilization Review Case Manager jobs?

Cities near Reston, VA with the most Utilization Review Case Manager job openings:

Utilization Review Case Manager jobs near you

Utilization Review Case Manager - Partial Hospitalization Program

Luminis Health

Lanham, MD

Full-time

Posted 6 days ago

Luminis Health rating

7.9

Company rating: 7.9 out of 10

Based on 54 frontline employees who took The Breakroom Quiz

108th of 893 rated healthcare providers

Job description

Luminis Health

Title:  Utilization Review/Case Manager-Partial Hospitalization Program   

Department:  Lanham Partial Hospitalization

Reports To:  Director- Clinical Director Behavioral Health Lanham

Cost Center/Job Code:  41000-42002-001148

FLSA Status: Exempt

Position Objective:

Performs and monitors integrated, concurrent utilization review and case referrals on patients, consistent with the approved Utilization Review Plans. Works with medical and professional staff to obtain appropriate clinical documentation for review and optimal patient placement. Maintains contact with Managed Care and other third party payors to assure appropriate case management.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

  1. Performs duties according to established standards for age groups adolescence through geriatric.
  2. Assesses data reflective of the patients status and interprets the appropriate information needed to identify each patients requirements relative to his or her age-specific needs.  Maintains monthly statistical data and reports data to Clinical Director.
  3. Identifies status of physical, social and psychological needs of the patient, family and significant others.
  4. Evaluates data obtained in the bio-psychosocial and nursing history and assesses patients and their families to determine by interview, appropriateness for admission or referral.
  5. Determines the medical necessity and appropriateness of admission, using established criteria and standards.
  6. Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
  7. Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
  8. Verifies prior authorization data and performs concurrent reviews with external review agents on a daily basis in order to provide medical necessity and intensity of service information for continued stay approvals.
  9. Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
  10. Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.

Educational/Experience Requirements:

  • BA/BS
  • Two years of experience performing utilization review or utilization management. 

RequiredLicense/Certifications:

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands -

Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

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