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Utilization Review Manager Jobs in Rio Rancho, NM

w3r Consulting

Utilization Review Nurse

Albuquerque, NM · On-site

Essential Duties and Responsibilities: • Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services ...

UnitiMed

RN Case Manager

Albuquerque, NM · On-site

Referral bonus up to $700 Registered Nurse (RN),Case Management/Utilization Review, About the Company: Uniti Med is an award-winning healthcare staffing company with a mission to provide staffing ...

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All JobsUtilization Review Manager JobsUtilization Review Manager Jobs in Rio Rancho, NM

Utilization Review Manager information

See Rio Rancho, NM salary details

$35.2K

$82.1K

$151.1K

How much do utilization review manager jobs pay per year?

As of Jun 9, 2026, the average yearly pay for utilization review manager in Rio Rancho, NM is $82,083.00, according to ZipRecruiter salary data. Most workers in this role earn between $53,700.00 and $98,800.00 per year, depending on experience, location, and employer.

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, and why are they important?

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.
What are the most commonly searched types of Utilization Review jobs in Rio Rancho, NM? The most popular types of Utilization Review jobs in Rio Rancho, NM are:
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Utilization Review Manager jobs near you
Utilization Review Nurse

Utilization Review Nurse

w3r Consulting

Albuquerque, NM • On-site

Full-time

Posted 25 days ago

Job description

Description:
Registered Nurse responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: drugs and biologics, inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.
Essential Duties and Responsibilities:
• Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.
• Uses an established set of criteria to evaluates and authorize the medical necessity of services.
• Provide notification of decisions in accordance with compliance guidelines.
• Coordinate with Medical Directors when services do not meet criteria or require additional review.
• Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.
• Works with management team to achieve operational objectives and financial goals.
• Supports teams across UM Department as needed.
• Active participation and completion of all required trainings.
• Maintain Required Licensures.
• Adherence to regulatory and departmental timeframes for review of requests
• Meet/exceed department Turn Around time, daily established productivity goals, and service levels
• Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards;
• Professional demeanor and the ability to work effectively within a team or independently;
• Flexible with the ability to shift priorities when required
• Other duties as required
Qualifications:
• Current unrestricted RN license. Multi-State License Preferred
• Bachelors degree in nursing or health-care related field preferred
• Minimum of 2 years experience in a regulated environment preferred
• Minimum of 2-3 years clinical experience
• Strong customer orientation
• Strong organizational, planning, and communication skills
• Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus
• Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.
• Excellent time management skills
Knowledge, Skills, Abilities Required:
• Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
• Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
• Able to work in a dynamic, fast-paced team environment and to promote team concepts
• Excellent typing skills.
• Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.

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