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Cvs Health Utilization Management Jobs in Raleigh, NC

Duke Health

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

Duke Health

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

Duke University

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

Duke University

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

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All JobsCvs Health Utilization Management JobsCvs Health Utilization Management Jobs in Raleigh, NC

Cvs Health Utilization Management information

See Raleigh, NC salary details

$37.9K

$88.5K

$162.8K

How much do cvs health utilization management jobs pay per year?

As of Aug 6, 2026, the average yearly pay for cvs health utilization management in Raleigh, NC is $88,470.00, according to ZipRecruiter salary data. Most workers in this role earn between $57,800.00 and $106,400.00 per year, depending on experience, location, and employer.

What is CVS Health Utilization Management?

CVS Health Utilization Management refers to a set of services and processes used to ensure that patients receive appropriate, effective, and efficient health care. This involves reviewing medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities under the provisions of a health benefits plan. At CVS Health, Utilization Management professionals work with healthcare providers, payers, and patients to optimize care outcomes while controlling costs. They help determine coverage decisions, coordinate care, and assist in managing complex cases.

What is the difference between Cvs Health Utilization Management vs Cvs Health Case Management?

AspectCvs Health Utilization ManagementCvs Health Case Management
Primary FocusReviewing and authorizing healthcare services to ensure appropriate utilizationCoordinating patient care and connecting patients with resources
Work EnvironmentUtilization review teams, insurance settingsPatient homes, healthcare facilities, community settings
CredentialsRN, LPN, or other healthcare certificationsRN, social worker, or case management certifications
Employer & Industry UsageHealth insurance companies, managed care organizationsHospitals, insurance companies, healthcare providers

While both roles involve healthcare professionals, Utilization Management focuses on reviewing services for appropriateness, whereas Case Management emphasizes coordinating comprehensive patient care. Understanding these differences helps in choosing the right career path or job search focus within the healthcare industry.

What are some typical challenges faced by CVS Health Utilization Management professionals, and how can they be addressed?

Utilization Management professionals at CVS Health often encounter challenges such as balancing clinical decision-making with cost-effectiveness, managing high caseloads, and navigating complex insurance policies. Staying updated on healthcare regulations, maintaining clear communication with providers, and leveraging the company's decision-support tools can help address these challenges. Regular collaboration with interdisciplinary teams also ensures that patient care remains the top priority while meeting organizational guidelines.

What are the key skills and qualifications needed to thrive in CVS Health Utilization Management?

To thrive as a CVS Health Utilization Management Nurse, you need a current RN license, strong clinical judgment, and experience in case management or utilization review. Familiarity with utilization review software, electronic health records (EHRs), and knowledge of insurance guidelines and regulatory requirements is typically expected. Excellent communication, attention to detail, and critical thinking skills help in advocating for patients and collaborating with healthcare providers. These skills ensure effective care coordination, compliance with policies, and optimized patient outcomes in a managed care environment.
What are the most commonly searched types of Cvs Health Utilization Management jobs in Raleigh, NC? The most popular types of Cvs Health Utilization Management jobs in Raleigh, NC are:
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What job categories do people searching Cvs Health Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Cvs Health Utilization Management jobs in Raleigh, NC are:
Cvs Health Utilization Management jobs near you
Infographic showing various Cvs Health Utilization Management job openings in Raleigh, NC as of July 2026, with employment types broken down into 56% Full Time, 39% Part Time, 4% Contract, and 1% Summer. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $88,470 per year, or $42.5 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Posted 29 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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