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Apprentice Utilization Management Nurse Jobs in Raleigh, NC

Duke University

Utilization Manager

Durham, NC · On-site

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke University

Utilization Manager

Durham, NC · On-site

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Supports denials management by documenting activities related to denials adjudication according to ...

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All JobsApprentice Utilization Management Nurse JobsApprentice Utilization Management Nurse Jobs in Raleigh, NC

Apprentice Utilization Management Nurse information

See Raleigh, NC salary details

$37.9K

$87K

$158.4K

How much do apprentice utilization management nurse jobs pay per year?

As of Jul 23, 2026, the average yearly pay for apprentice utilization management nurse in Raleigh, NC is $86,984.00, according to ZipRecruiter salary data. Most workers in this role earn between $62,700.00 and $101,600.00 per year, depending on experience, location, and employer.

What is the difference between Apprentice Utilization Management Nurse vs Utilization Management Nurse?

AspectApprentice Utilization Management NurseUtilization Management Nurse
CredentialsLicensed RN, in training or early certification stageLicensed RN with certification in utilization review
Work EnvironmentSupervised training setting, often in healthcare or insurance companiesIndependent review in healthcare or insurance organizations
Job ResponsibilitiesAssisting with case reviews, learning utilization review processesConducting case assessments, making coverage decisions

The Apprentice Utilization Management Nurse is in training, focusing on learning review procedures under supervision, while the Utilization Management Nurse is fully qualified, responsible for independent case evaluations and decision-making. The apprentice role is a stepping stone toward becoming a licensed Utilization Management Nurse.

What are the key skills and qualifications needed to thrive as an Apprentice Utilization Management Nurse, and why are they important?

To thrive as an Apprentice Utilization Management Nurse, you need a foundational understanding of nursing principles, strong analytical skills, and typically an RN license or progression toward one. Familiarity with utilization management software, electronic health records (EHR), and knowledge of insurance guidelines such as Medicare or Medicaid are often required. Attention to detail, critical thinking, and effective communication are essential soft skills for collaborating with healthcare teams and conveying clinical information. These competencies ensure accurate patient care reviews, compliance with regulations, and effective support in healthcare cost management.

What are some common challenges faced by Apprentice Utilization Management Nurses, and how can they be addressed?

Apprentice Utilization Management Nurses often encounter challenges such as learning to interpret complex medical records, understanding insurance policies, and adhering to strict regulatory guidelines. Balancing patient advocacy with cost-effective care decisions can also be demanding. These challenges can be addressed by actively participating in mentorship programs, seeking regular feedback from experienced colleagues, and utilizing ongoing training resources provided by employers. Developing strong communication and organizational skills will also help manage the workload and foster effective collaboration with physicians, case managers, and insurance representatives.

What is an Apprentice Utilization Management Nurse?

An Apprentice Utilization Management Nurse is a nursing professional in training who assists with the review and evaluation of healthcare services to ensure they are medically necessary and cost-effective. They work under the supervision of experienced utilization management nurses and follow established guidelines to assess patient care plans, medical records, and insurance policies. Their role is crucial in helping healthcare organizations maintain quality care while managing costs, and they may interact with physicians, patients, and insurance companies to clarify or justify treatment decisions. As apprentices, they are gaining hands-on experience to develop their skills and knowledge in utilization management.
What are the most commonly searched types of Utilization Management Nurse jobs in Raleigh, NC? The most popular types of Utilization Management Nurse jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Apprentice Utilization Management Nurse jobs? Cities near Raleigh, NC with the most Apprentice Utilization Management Nurse job openings:
Apprentice Utilization Management Nurse jobs near you
Utilization Management Nurse

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Posted 16 days ago

Job description

About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
•    Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
•    Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
•    Collaborates with healthcare partners to ensure timely review of services and care.
•    Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
•    Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
•    Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
•    Triages and prioritizes cases and other assigned duties to meet required turnaround times.
•    Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
•    Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
•    Duties as assigned.
Essential Qualifications
•    Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
•    Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
•    Must be able to work independently.
•    Must be detail oriented and have strong organizational and time management skills.
•    Adaptive to a high pace and changing environment- flexibility in assignment.
•    Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
•    Proficient in MCG and CMS criteria sets
•    Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
•    Working knowledge of URAC and NCQA.
•   2+ years’ experience in a UM team within managed care setting.
•   3+ years’ experience in clinical nurse setting preferred.
•   TPA Experience preferred.

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