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Utilization Review Manager Jobs in Rhode Island (NOW HIRING)

VNA of Care New England

RN Case Manager

Providence, RI · On-site

Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager

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Utilization Review Manager information

See Rhode Island salary details

$38.2K

$89.1K

$164K

How much do utilization review manager jobs pay per year?

As of Aug 5, 2026, the average yearly pay for utilization review manager in Rhode Island is $89,128.00, according to ZipRecruiter salary data. Most workers in this role earn between $58,300.00 and $107,200.00 per year, depending on experience, location, and employer.

Is utilization review a stressful job?

Utilization review managers oversee the assessment of healthcare services to ensure appropriate and efficient care, which can involve high workloads and strict deadlines, leading to stress. The job requires strong organizational skills, attention to detail, and the ability to handle complex cases, which may contribute to job-related stress for some individuals.

What are some common challenges faced by utilization review managers in balancing patient care and cost efficiency?

Utilization Review Managers often encounter the challenge of ensuring patients receive appropriate care while also adhering to insurance and regulatory guidelines that emphasize cost efficiency. This requires strong analytical skills to assess clinical information and make fair determinations, often under tight deadlines and with incomplete data. The role also involves frequent communication with physicians, payers, and case managers to resolve disagreements and clarify criteria, making negotiation and diplomacy essential. Staying updated on changing healthcare regulations and payer requirements can add to the complexity, but it also provides opportunities for professional growth and leadership within healthcare administration.

What are the key skills and qualifications needed to thrive as a utilization review manager?

To thrive as a Utilization Review Manager, you need a solid background in healthcare management, clinical knowledge (often as an RN or healthcare professional), and experience with utilization review processes. Familiarity with case management software, electronic health records (EHRs), and certifications such as Certified Case Manager (CCM) or Certified Professional in Utilization Review (CPUR) are often expected. Strong analytical thinking, attention to detail, leadership, and effective communication are crucial soft skills for success in this role. These skills ensure appropriate resource use, regulatory compliance, and coordinated patient care, which are vital for both healthcare quality and operational efficiency.

What is the difference between Utilization Review Manager vs Utilization Review Coordinator?

AspectUtilization Review ManagerUtilization Review Coordinator
CertificationsTypically requires certifications like CCM or ACUMay require similar certifications but often less advanced
Work EnvironmentSupervises review teams, manages processes in healthcare or insurance settingsPerforms case reviews, supports the review process under supervision
Employer & IndustryHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare providers, third-party administrators

The Utilization Review Manager oversees review teams and manages utilization review processes, focusing on policy compliance and efficiency. The Utilization Review Coordinator supports the review process by conducting case assessments and assisting managers. While both roles require similar certifications and work in related environments, the manager holds a supervisory position with broader responsibilities.

What does a utilization review manager do?

A Utilization Review Manager oversees the process of evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. They ensure that patient care adheres to established guidelines and that healthcare resources are used effectively. Their duties typically include leading a team of reviewers, collaborating with healthcare providers, ensuring compliance with regulations, and making recommendations on care authorization. The goal is to balance quality patient care with cost-effective resource management.
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Utilization Review Manager jobs near you

Utilization Review Nurse

US Tech Solutions

Providence, RI • On-site

Other

Re-posted 11 days ago

Job description

Please note: Actual location may vary., RI

Contract

Job Description:

· Participates in the development and ongoing implementation of QM Work Plan activities.

· Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives

Responsibilities:

· Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.

· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.

· Data gathering requires navigation through multiple system applications.

· Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.

· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.

· Responsible for the review and evaluation of clinical information and documentation.

· Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.

· Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).

· Independently coordinates the clinical resolution with internal/external clinician support as required.

· Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data

· Prepares and completes QM documents based on interpretation and application of business requirements

· Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements

· Assists in the development and implementation of QM projects and activities

· Accountable for completing and implementation of QM Work Plan Activities

Experience:

· 3+ years of experience as an RN

· 1+ years of inpatient hospital experience

· Registered Nurse in state of residence

· Must have prior authorization utilization experience

· Able to work in multiple IT platforms/systems

Skills:

· MUST HAVE MEDCOMPASS or ASSURECARE exp.

· MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.

· MUST HAVE UM experience, inpatient utilization management review.

· MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.

· MUST HAVE 6 months of Prior Authorization.

Education:

· Active and unrestricted RN licensure in state of residence

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com/) .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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About US Tech Solutions

Sourced by ZipRecruiter

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

Industry

It services

Company size

1,001 - 5,000 Employees

Headquarters location

Jersey City, NJ, US

Year founded

2000

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