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Cvs Health Utilization Management Jobs in Raleigh, NC

CVS Health

Staff Pharmacist Full Time

Selma, NC · On-site

$60 - $76/hr

At CVS Health ® , you'll be surrounded by passionate colleagues who care deeply, innovate with ... Inventory Management * Financial Profitability * Loss Prevention * Workflow Management A key ...

CVS Health

Store Associate

Oxford, NC · On-site

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Store Associate

Rolesville, NC

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Store Associate

Oxford, NC · On-site

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Operations Manager

Cary, NC · On-site

$19 - $29/hr

... Management team, and as such, fulfills the company purpose of helping people on their path to better health by driving store execution and performance while building consumer loyalty to CVS/pharmacy ...

CVS Health

Store Associate

Raleigh, NC

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Store Associate

Rolesville, NC · On-site

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Store Manager in Training

Cary, NC

$18.50 - $23.88/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... Support your store as management team member and lead in a manner that is consistent with CVS ...

CVS Health

Operations Manager

Cary, NC

$19 - $29/hr

... Management team, and as such, fulfills the company purpose of helping people on their path to better health by driving store execution and performance while building consumer loyalty to CVS/pharmacy ...

CVS Health

Store Associate

Cary, NC · On-site

$15 - $19/hr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... directed by store manager * Supporting opening and closing store activities, when needed

CVS Health

Operations Manager

Louisburg, NC

$19 - $29/hr

... Management team, and as such, fulfills the company purpose of helping people on their path to better health by driving store execution and performance while building consumer loyalty to CVS/pharmacy ...

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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:
What are popular job titles related to Cvs Health Utilization Management jobs in Raleigh, NC? For Cvs Health Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
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 August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 18% Part Time, and 5% Contract. 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.

UM Clinical Specialist RN-Physical Health (Full-time Remote, NC Based)

Alliance

Morrisville, NC • On-site, Remote

$69K - $88K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 18 days ago

Job description

The Utilization Management (UM) Clinical Specialist RN for physical health (PH) independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services, monitors consumer treatment through ongoing and continuous review to ensure that services are delivered based on consumer need and established clinical guidelines, and identifies and follows-up on clinical cases of concern and high-risk/special needs consumers to ensure enrollees are linked to appropriate treatment resources. The UM Clinical Specialist RN - PH may represent the unit in cross agency collaborative needs.
This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to one of the offices for business or onsite team meetings as needed.
Responsibilities & Duties
Assesses the medical necessity of services
  • Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
  • Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers
  • Provide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member's needs
  • Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts
  • Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards
  • Notify members of adverse benefit determinations while preserving members' Due Process rights
  • Ensure compliance with performance measures outlined within all accrediting body standards
  • Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators

Compliance
  • Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standards
  • Comply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees

Coordinate and Implement UM Processes
  • Participate in the integration of the department and its functions into the organization's primary mission
  • Take part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral Health

Collaborate with other departments
  • Monitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers.
  • Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO.
  • Maintain open, timely communication with staff, providers, community agencies and other stakeholders

Minimum Requirements
Education & Experience
Graduation from a State accredited school of nursing or an Associate's Degree in Nursing from an accredited and five years of experience with five (5) years nursing experience
OR
Bachelor's degree in Nursing from an accredited college/university and three (3) years of nursing experience
Special Requirement
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
Preferred Experience:
Experience in Utilization Management
Knowledge, Skills, & Abilities
  • Knowledge of physical health and co-morbid health conditions
  • Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
  • Proficient in the use of computer and multiple software programs.
  • Written and oral communication skills
  • Ability to interact with a wide variety of individuals and handle complex and confidential sensitive situations.
  • Knowledge of Utilization Management managed care principles and strategies
  • Ability to analyze effectiveness of processes and adjust developed processes.
  • Knowledge of and experience in acute clinical utilization review
  • Knowledge of Authorization/re-authorization Utilization Management standards
  • Knowledge of related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
  • Ability to lead, delegate and problem solve
  • Ability to develop and document workflows
  • Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.
  • Knowledge of and experience with NCQA

Salary Range
$69,592-$88,729/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
  • Medical, Dental, Vision, Life, Long Term Disability
  • Generous retirement savings plan
  • Flexible work schedules including hybrid/remote options
  • Paid time off including vacation, sick leave, holiday, management leave
  • Dress flexibility

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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