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Insurance Utilization Reviewer Jobs in Raleigh, NC

Centene

Psychologist Reviewer

Durham, NC · On-site +1

$87K - $157K/yr

Interact with network practitioners to provide education on best practice models and utilization ... pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus ...

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 ...

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 ...

UNC Medical Center

RN - Case Manager

Chapel Hill, NC · On-site

... utilization review, and discharge planning. The Care Manager must be a highly organized ... Medical, dental & vision insurance * Free and unlimited continuing education units (CEUs) * 24/7 ...

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Insurance Utilization Reviewer information

See Raleigh, NC salary details

$30.1K

$36.9K

$42.8K

How much do insurance utilization reviewer jobs pay per year?

As of Aug 22, 2026, the average yearly pay for insurance utilization reviewer in Raleigh, NC is $36,932.00, according to ZipRecruiter salary data. Most workers in this role earn between $33,000.00 and $40,800.00 per year, depending on experience, location, and employer.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are popular job titles related to Insurance Utilization Reviewer jobs in Raleigh, NC?

For Insurance Utilization Reviewer jobs in Raleigh, NC, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in Raleigh, NC look for?

The top searched job categories for Insurance Utilization Reviewer jobs in Raleigh, NC are:

Insurance Utilization Reviewer jobs near you
Infographic showing various Insurance Utilization Reviewer job openings in Raleigh, NC as of July 2026, with employment types broken down into 86% Full Time, and 14% Part Time. Highlights an 95% In-person, and 5% Remote job distribution, with an average salary of $36,932 per year, or $17.8 per hour.

Utilization Review Specialist

Lifepoint Health

Raleigh, NC • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 4 days ago

LifePoint Health rating

5.9

Company rating: 5.9 out of 10

Based on 272 frontline employees who took The Breakroom Quiz

762nd of 891 rated healthcare providers

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.

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.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.

What LifePoint Health employees say

Pay

Benefits

Hours and flexibility

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About LifePoint Health

Sourced by ZipRecruiter

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

Social media

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