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Insurance Utilization Reviewer Jobs in Raleigh, NC

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 2, 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 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 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 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 are Insurance Utilization Reviewers?

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 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.

Case Manager - Utilization Review

Granville Health System

Oxford, NC • Hybrid

Full-time

Medical, Dental, Vision, Life, Retirement

Re-posted 14 days ago

Granville Health System rating

8.6

Company rating: 8.6 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Job description

Case Manager - Utilization Review
Location: Granville Health System, Oxford NC

About Granville Health System:

For over a century, Granville Health System has been at the forefront of quality healthcare. To cater to the evolving needs of its community, Granville Health System has extended its services throughout Granville County, ensuring convenient medical care access for its residents. The Granville Health System main campus can be found at 1010 College Street, Oxford, North Carolina. For more details, visit GHS online at www.ghsHospital.org.

About Oxford, NC

Oxford, NC is a charming and welcoming community that offers a perfect blend of small-town charm and modern convenience, making it an ideal place to live and work. Located just about 30 miles north of Durham and 40 miles from Raleigh. The region enjoys a mild, four-season climate with warm summers, crisp autumns, blooming springs, and gentle winters—perfect for enjoying the area's outdoor activities year-round. With a thriving local economy, excellent healthcare facilities, and a strong sense of community, its historic downtown, scenic parks, and proximity to the Research Triangle ensure a balanced lifestyle with both professional and personal fulfillment.

Position Overview:
The primary role of the Case Manager is to review and monitor members’ utilization of health care services with the goal of maintaining high quality, cost-effective care. This role will provide the medical and utilization review expertise necessary to evaluate patient status.  This includes reviewing clinical information against established criteria, assessing the medical necessity of services and procedures, collaborating with providers and interdisciplinary teams, and ensuring that the patient is placed at the appropriate level of care from the time of admission. This includes providing referral authorization, concurrent review, proactive discharge/transition planning, appropriate referral to case management, and high-dollar claims review.

Position Highlights:

  • Retirement Benefits: NC Local Government Pension Plan (5-year vesting period)
  • Loan Forgiveness: Eligible employer for Public Service Loan Forgiveness (PSLF)
  • Comprehensive Benefits: Medical, dental, vision, life insurance, and various supplemental benefits available

Key Responsibilities:

• Conduct concurrent review of all patients, regardless of payer source, using approved screening criteria

• Perform admission reviews on the first working day following admission

• Conduct continued stay reviews at least every three (3) days or more frequently as indicated

Qualifications

Associate degree in a healthcare-related field or equivalent combination of healthcare experience and education.                                                                    

At least a year of experience in a related role (utilization review, case management, care coordination, insurance authorization/prior authorization, clinical documentation review, hospital patient access or revenue cycle support, healthcare quality or compliance functions).

Strong attention to detail, organizational skills and interpersonal skills.  Ability to interpret clinical documentation and apply review criteria.  Strong communication skills for interaction with physicians and interdisciplinary teams.  Knowledge of healthcare regulations and payer requirements

Preferred

Bachelor’s degree in Health Administration, Public Health, Social Work, Healthcare Management, or related field. Accredited Case Manager (ACM) certification. 

Experience with insurance authorization criteria preferred; one year utilization and discharge planning experience.

Apply Today:
If you're a dedicated professional looking for a position with a focus on work-life balance and the opportunity to make a difference, we encourage you to apply for this position with Granville Health System.

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