ZipRecruiter

Log In

1

Insurance Utilization Review Jobs in Raleigh, NC

UMHS

CQI Specialist - Raleigh

Raleigh, NC · On-site

$12/hr

Prior CQI, compliance, or utilization review experience * Experience working with LME/MCOs (Vaya ... Medical Insurance (Full Time) * Dental Insurance * Vision * Telehealth- Online Doctor (Teledoc ...

WakeMed

Mental Health Case Manager I

Raleigh, NC · On-site

Assists with insurance appeals and utilization reviews. Supports clinical staff with coverage guidance and medical record reviews. Participates in the involuntary commitment process, including case ...

WakeMed

Mental Health Case Manager I

Raleigh, NC · On-site

Assists with insurance appeals and utilization reviews. Supports clinical staff with coverage guidance and medical record reviews. Participates in the involuntary commitment process, including case ...

Elevance Health

Pharmacist Clinical

Raleigh, NC · On-site

$115K - $137K/yr

... when conducting utilization review or an appeals consideration and cannot be located on a US ... insurance, wellness programs and financial education resources, to name a few. Elevance Health ...

WakeMed

Mental Health Case Manager I

Raleigh, NC · On-site

Assists with insurance appeals and utilization reviews. Supports clinical staff with coverage guidance and medical record reviews. Participates in the involuntary commitment process, including case ...

Elevance Health

Pharmacist Clinical

Durham, NC

$111K - $133K/yr

... when conducting utilization review or an appeals consideration and cannot be located on a US ... insurance, wellness programs and financial education resources, to name a few. Elevance Health ...

Elevance Health

Pharmacist Clinical

Durham, NC · On-site

$114K - $136K/yr

... when conducting utilization review or an appeals consideration and cannot be located on a US ... insurance, wellness programs and financial education resources, to name a few. Elevance Health ...

Elevance Health

Pharmacist Clinical

Raleigh, NC

$115K - $137K/yr

... when conducting utilization review or an appeals consideration and cannot be located on a US ... insurance, wellness programs and financial education resources, to name a few. Elevance Health ...

Elevance Health

Pharmacist Clinical

Raleigh, NC · On-site

$105K - $126K/yr

... when conducting utilization review or an appeals consideration and cannot be located on a US ... insurance, wellness programs and financial education resources, to name a few. Elevance Health ...

next page

Showing results 1-20

All JobsInsurance Utilization Review JobsInsurance Utilization Review Jobs in Raleigh, NC

Insurance Utilization Review information

See Raleigh, NC salary details

$20

$41

$67

How much do insurance utilization review jobs pay per hour?

As of Jun 14, 2026, the average hourly pay for insurance utilization review in Raleigh, NC is $41.10, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.21 per hour, depending on experience, location, and employer.

What are the most common challenges faced by Insurance Utilization Review professionals?

One common challenge in Insurance Utilization Review is balancing the need for cost-effective care with the clinical needs of patients, which often requires careful analysis and decision-making. Professionals in this role frequently navigate complex medical records, strict policy guidelines, and collaborate with healthcare providers who may advocate strongly for particular treatments. Managing challenging conversations while maintaining professionalism and ensuring timely determinations are also a regular part of the role. Developing expertise in these areas can make the job both demanding and rewarding, while building a strong foundation for career growth within healthcare administration.

What are the key skills and qualifications needed to thrive in the Insurance Utilization Review position, and why are they important?

To thrive in Insurance Utilization Review, you generally need a strong background in healthcare or nursing, an understanding of medical terminology, and analytical thinking skills, often supported by an RN license or relevant clinical experience. Familiarity with utilization management software, coding systems like ICD-10, and knowledge of regulatory requirements (such as Medicare or Medicaid) are important. Strong communication, attention to detail, and problem-solving abilities help professionals excel when interacting with providers and insurers. These skills are essential to ensure appropriate care is authorized while maintaining regulatory compliance and cost-effectiveness.

What is an Insurance Utilization Review job?

An Insurance Utilization Review job involves evaluating medical treatments and services to determine if they are necessary, appropriate, and covered by a patient's insurance plan. Professionals in this role review medical records, treatment plans, and insurance policies to ensure compliance with guidelines and cost-effectiveness. They work closely with healthcare providers, insurance companies, and patients to facilitate approvals or appeals. The goal is to balance quality patient care with cost containment in the healthcare system.

What are the most commonly searched types of Insurance Utilization Review jobs in Raleigh, NC? The most popular types of Insurance Utilization Review jobs in Raleigh, NC are:
What are popular job titles related to Insurance Utilization Review jobs in Raleigh, NC? For Insurance Utilization Review jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Review jobs in Raleigh, NC look for? The top searched job categories for Insurance Utilization Review jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Insurance Utilization Review jobs? Cities near Raleigh, NC with the most Insurance Utilization Review job openings:
Insurance Utilization Review jobs near you
Utilization Management Representative I

Utilization Management Representative I

Elevance Health

Durham, NC • On-site

Other

Medical, Dental, Vision, Life, Retirement, PTO

Posted 29 days ago

Elevance Health rating

7.8

Company rating: 7.8 out of 10

Based on 332 frontline employees who took The Breakroom Quiz

166th of 261 rated insurance

Job description

Utilization Management Representative I

Location: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.


The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review.

Hours: Training is conducted from 7:00 AM to 3:30 PM Mountain Time, with standard shift hours from 8:30 AM to 5:30 PM Mountain Time. Please adjust for your time zone. Candidates will be required to work rotating weekends and select holidays, and must be flexible and available to work overtime. Weekend shift hours may vary.

How you will make an impact:

  • Managing incoming calls or incoming post services claims work.

  • Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.

  • Refers cases requiring clinical review to a Nurse reviewer.

  • Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.

  • Responds to telephone and written inquiries from clients, providers and in-house departments.

  • Conducts clinical screening process.

  • Authorizes initial set of sessions to provider.

  • Checks benefits for facility based treatment.

  • Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

  • Associates in this role are expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.

  • Additional expectations to include but not limited to: Proficient in maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment; strong verbal and written communication skills, both with virtual and in-person interactions; attentive to details, critical thinker, and a problem-solver; demonstrates empathy and persistence to resolve caller issues completely; comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts.

  • Associates in this role will have a structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.

  • Performs other duties as assigned.

Minimum Requirements:

  • Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

  • Inbound call center experience strongly preferred.

  • Medical terminology training and experience in medical or insurance field strongly preferred.

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

What Elevance Health employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Elevance Health logo

About Elevance Health

Sourced by ZipRecruiter

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Indianapolis, IN, US

Year founded

2004

Social media

FacebookTwitter

View All Elevance Health Jobs

Apply