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Insurance Utilization Review Jobs in Raleigh, NC

Senture

Medical Director

Raleigh, NC · Remote

... utilization review, credentialing, claims resolution, or medical review functions within commercial and/or government-sponsored health insurance programs. * Demonstrated knowledge of NCQA ...

Senture

Medical Director

Raleigh, NC · On-site

... utilization review, credentialing, claims resolution, or medical review functions within commercial and/or government-sponsored health insurance programs. * Demonstrated knowledge of NCQA ...

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How much do insurance utilization review jobs pay per hour?

As of Aug 27, 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 is an insurance utilization review?

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 key skills and qualifications needed to thrive in insurance utilization review?

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 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.

How do I get into an insurance utilization review?

To become an insurance utilization review specialist, candidates typically need a background in healthcare, nursing, or a related field, along with knowledge of insurance policies and medical terminology. Certification such as the Certified Professional in Healthcare Quality (CPHQ) or similar credentials can enhance job prospects. Relevant skills include attention to detail, analytical thinking, and familiarity with medical records and insurance software systems.

Is insurance utilization review a stressful job?

Insurance utilization review can be stressful due to the need for accuracy, attention to detail, and meeting strict deadlines. Reviewers often handle complex cases and must balance policy guidelines with patient needs, which can contribute to job pressure. However, the level of stress varies depending on workload, work environment, and individual coping skills.

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
Infographic showing various Insurance Utilization Review job openings in Raleigh, NC as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 17% Part Time, and 6% Contract. Highlights an 84% Physical, 1% Hybrid, and 15% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

Utilization Review Specialist

Raleigh, NC • On-site

Lifepoint Health
Health Care and Social Assistance • 10K+ employees

5.9

Company rating: 5.9 out of 10

Based on 272 frontline employees who took The Breakroom Quiz

764th of 893 rated healthcare providers

People enjoy working here

Recommended by students

Recommended by parents

Learn more about Lifepoint Healthexternal

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 9 days ago

Job description


Your experience matters
Lifepoint Behavioral Health is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. Triangle Springs is a 77-bed behavioral health hospital located in Raleigh, North Carolina, providing care for patients with mental health and substance use disorders. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Registered Nurse (RN) joining our team, you're embracing a vital mission dedicated to making communities healthier®. Join us on this meaningful journey where your skills, compassion, and dedication will make a remarkable difference in the lives of those we serve.
How you'll contribute
Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine legitimacy of admission, treatment, and length of stay and interfaces with managed care organizations, external reviewers and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to manage care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.
Job Responsibilities
  • Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services
  • Complete pre and re-certifications for inpatient and outpatient services. Reports appropriate denial, and authorization information to designated resource.
  • Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
  • Participate in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
  • Works with DON to ensure documentation requirements are met.
  • Ensure appeals are completed thoroughly and on a timely basis.
  • Interface with managed care organizations, external reviews, and other payers.
  • Communicate with physicians to schedule peer-to-peer reviews.

What we're looking for
Education: Bachelor's degree required. Master's degree preferred.
Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
License: Current unencumbered clinical license strongly preferred.
Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred.
Why join us
We believe that investing in our employees is the first step to providing excellent patient care. In addition to your base compensation, this position also offers:
Comprehensive Benefits: Multiple levels of medical, dental, and vision coverage for full-time and part-time employees
Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave, and paid time off
Financial & Career Growth: Tuition reimbursement and 401(k) retirement package with company match
Employee Well-being: Mental, physical, and financial wellness programs, including Employee Assistance Program and discount programs
Professional Development: Ongoing learning and career advancement opportunities
Additional Perks: Shift differentials and set schedules
EEOC Statement
Lifepoint Behavioral Health is an Equal Opportunity Employer. Lifepoint Behavioral Health is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.
About Us
Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.
About the Team
We employ and provide care to people from all walks of life. We are committed to promoting healing, providing hope, preserving dignity and producing value with an inclusive workforce in which diversity is leveraged, respected, and reflective of the patients, family members, customers and team members we serve.
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About LifePoint Health

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Lifepoint Health serves patients, clinicians, communities and partners across the healthcare continuum. Our diversified healthcare delivery network extends from coast to coast, consisting of community hospitals, rehabilitation and behavioral health hospitals, and additional sites of care.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Brentwood, TN, US

Year founded

1999

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Benefits

Hours and flexibility

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