The Utilization Management Nurse performs medical necessity and benefit review requests in ... Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity ...
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The Utilization Management Nurse performs medical necessity and benefit review requests in ... Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity ...
Utilization Management Nurse
Chapel Hill, NC · On-site +1
The Utilization Management Nurse performs medical necessity and benefit review requests in ... Director (MD) for medical director oversight and necessity determinations. • Communicates ...
Utilization Management Nurse
Chapel Hill, NC · On-site +1
The Utilization Management Nurse performs medical necessity and benefit review requests in ... Director (MD) for medical director oversight and necessity determinations. • Communicates ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Manager
Durham, NC · On-site
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Supports denials management by documenting activities related to denials adjudication according to ... ED, Direct Admit, Transfers). * Manage concurrent cases to resolution care that may impact payer ...
Utilization Review Nurse
Oxford, NC · On-site
... to Director when needed. Screens all cases against high risk screens for discharge planning ... Self direction with the ability to work with minimal supervision and manage multiple tasks.
Utilization Review Nurse
Oxford, NC · On-site
... to Director when needed. Screens all cases against high risk screens for discharge planning ... Self direction with the ability to work with minimal supervision and manage multiple tasks.
Utilization Review Nurse
Oxford, NC · On-site
... to Director when needed. Screens all cases against high risk screens for discharge planning ... Self direction with the ability to work with minimal supervision and manage multiple tasks.
Utilization Review Nurse
Oxford, NC · On-site
... to Director when needed. Screens all cases against high risk screens for discharge planning ... Self direction with the ability to work with minimal supervision and manage multiple tasks.
Medical Director-Physical Health (Full-time Remote, North Carolina Based)
Morrisville, NC · Hybrid
$211K - $269K/yr
Ensure the integrity and quality of utilization management activities, including initial reviews ... Director OneNote--to complete timely utilization reviews in Alliance's UM platform and perform ...
Medical Director-Physical Health (Full-time Remote, North Carolina Based)
Morrisville, NC · Hybrid
$211K - $269K/yr
Ensure the integrity and quality of utilization management activities, including initial reviews ... Director OneNote--to complete timely utilization reviews in Alliance's UM platform and perform ...
Medical Director-Physical Health (Full-time Remote, North Carolina Based)
Smithfield, NC · Hybrid
$211K - $269K/yr
Ensure the integrity and quality of utilization management activities, including initial reviews ... Director OneNote--to complete timely utilization reviews in Alliance's UM platform and perform ...
Medical Director-Physical Health (Full-time Remote, North Carolina Based)
Smithfield, NC · Hybrid
$211K - $269K/yr
Ensure the integrity and quality of utilization management activities, including initial reviews ... Director OneNote--to complete timely utilization reviews in Alliance's UM platform and perform ...
As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical ...
As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical ...
Medical Director
Raleigh, NC · On-site
This position will support as a consulting Medical Director role supporting a Credentialing Verification Organization (CVO), health plan, or utilization management operation The Medical Director ...
Medical Director
Raleigh, NC · On-site
This position will support as a consulting Medical Director role supporting a Credentialing Verification Organization (CVO), health plan, or utilization management operation The Medical Director ...
Medical Director
Raleigh, NC · Remote
This position will support as a consulting Medical Director role supporting a Credentialing Verification Organization (CVO), health plan, or utilization management operation The Medical Director ...
Medical Director
Raleigh, NC · Remote
This position will support as a consulting Medical Director role supporting a Credentialing Verification Organization (CVO), health plan, or utilization management operation The Medical Director ...
Patient Flow Coordinator, RN - Capacity & Transfer Management
Raleigh, NC · On-site
$85 - $105/hr
... utilization management regulatory requirements. The Capacity and Transfer Management Center provides direct coordination of internal patient flow and external transfers through comprehensive ...
Patient Flow Coordinator, RN - Capacity & Transfer Management
Raleigh, NC · On-site
$85 - $105/hr
... utilization management regulatory requirements. The Capacity and Transfer Management Center provides direct coordination of internal patient flow and external transfers through comprehensive ...
Patient Flow Coordinator, RN - Capacity & Transfer Management
Raleigh, NC · On-site
$15.50 - $20.50/hr
... utilization management regulatory requirements. The Capacity and Transfer Management Center provides direct coordination of internal patient flow and external transfers through comprehensive ...
Patient Flow Coordinator, RN - Capacity & Transfer Management
Raleigh, NC · On-site
$15.50 - $20.50/hr
... utilization management regulatory requirements. The Capacity and Transfer Management Center provides direct coordination of internal patient flow and external transfers through comprehensive ...
Field Medical Director, Vascular Surgeon
Raleigh, NC · On-site
$130 - $140/hr
As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical ...
Field Medical Director, Vascular Surgeon
Raleigh, NC · On-site
$130 - $140/hr
As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical ...
Director Utilization Management information
See Raleigh, NC salary details
$17.5K - $23.3K
1% of jobs
$23.3K - $29.2K
3% of jobs
$29.2K - $35K
11% of jobs
$38.8K is the 25th percentile. Wages below this are outliers.
$35K - $40.8K
16% of jobs
$40.8K - $46.7K
15% of jobs
The median wage is $48.4K / yr.
$46.7K - $52.5K
16% of jobs
$57.3K is the 75th percentile. Wages above this are outliers.
$52.5K - $58.3K
17% of jobs
$58.3K - $64.2K
9% of jobs
$64.2K - $70K
7% of jobs
$70K - $75.8K
3% of jobs
$75.8K - $81.7K
2% of jobs
$17.5K
$50.9K
$81.7K
How much do director utilization management jobs pay per year?
As of Sep 3, 2026, the average yearly pay for director utilization management in Raleigh, NC is $50,861.00, according to ZipRecruiter salary data. Most workers in this role earn between $38,900.00 and $58,300.00 per year, depending on experience, location, and employer.
What is a director utilization management?
A Director of Utilization Management oversees the review and approval of medical services to ensure they are necessary, efficient, and cost-effective. They develop strategies to improve care quality while managing healthcare costs, working closely with providers, payers, and regulatory bodies. Their responsibilities include policy development, compliance with healthcare regulations, and leading a team of utilization review professionals. This role is common in hospitals, insurance companies, and managed care organizations.
What are the typical daily responsibilities of a director utilization management?
A Director Utilization Management generally oversees a team responsible for reviewing patient care to ensure appropriate resource use and compliance with payer requirements. Daily tasks may include analyzing utilization data, developing policy and process improvements, collaborating with clinical and administrative staff, and addressing escalated cases or issues. Directors frequently attend strategy meetings, conduct staff training, and engage with external partners like insurance providers. This role requires balancing administrative oversight with hands-on problem solving to support both cost efficiency and quality patient care.
What are the key skills and qualifications needed to thrive in the director utilization management position, and why are they important?
To thrive as a Director Utilization Management, you need a strong background in healthcare administration, case management, and data-driven decision-making, often supported by a clinical degree and several years of management experience. Familiarity with utilization management software, electronic health records (EHRs), and certifications such as CCM or ACM are typically valued. Exceptional leadership, communication, and problem-solving skills distinguish top performers in this role. These competencies are vital for optimizing resource use, ensuring regulatory compliance, and leading teams to meet quality care standards.
What does a director of utilization management do?
A director of utilization management oversees the review and approval of healthcare services to ensure they are medically necessary and cost-effective. They develop policies, manage teams of reviewers, and collaborate with healthcare providers and insurance companies to optimize patient care and resource utilization.
What are the most commonly searched types of Utilization Management jobs in Raleigh, NC?
The most popular types of Utilization Management jobs in Raleigh, NC are:
What are popular job titles related to Director Utilization Management jobs in Raleigh, NC?
For Director Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
- Remote Utilization Management
- Utilization Management
- Hospice Care Cna
- Healthcare Revenue Cycle Manager
- Part Time Utilization Management Nurse
- Manager Utilization Management
- Senior Cvs Health Utilization Management
- Cigna Medical Director
- Remote Cvs Utilization Management Nurse
- Entry Level Utilization Management Nurse
What job categories do people searching Director Utilization Management jobs in Raleigh, NC look for?
The top searched job categories for Director Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Director Utilization Management jobs?
Cities near Raleigh, NC with the most Director Utilization Management job openings:
Full-time
Re-posted 27 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.
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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About Brighton Health Plan Solutions
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