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Manager Aetna Utilization Review Jobs in Raleigh, NC

Duke Health

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke University

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke University

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke Health

Utilization Manager

Durham, NC

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

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Manager Aetna Utilization Review information

See Raleigh, NC salary details

$37.9K

$88.5K

$162.8K

How much do manager aetna utilization review jobs pay per year?

As of Sep 2, 2026, the average yearly pay for manager aetna utilization review in Raleigh, NC is $88,470.00, according to ZipRecruiter salary data. Most workers in this role earn between $57,800.00 and $106,400.00 per year, depending on experience, location, and employer.

What does a manager in Aetna Utilization Review do?

A Manager of Aetna Utilization Review oversees the process of evaluating medical necessity, appropriateness, and efficiency of healthcare services for Aetna-insured members. They manage a team of utilization review nurses or specialists who review patient records and coordinate with healthcare providers to ensure compliance with Aetna’s policies. Their main goal is to ensure patients receive necessary care while controlling costs and preventing unnecessary treatments. Additionally, they may handle appeals, train staff, and implement process improvements.

What key skills and qualifications are needed to thrive as a manager in Aetna Utilization Review?

To thrive as a Manager in Aetna Utilization Review, you need a strong background in healthcare management, clinical knowledge (often as an RN or similar licensure), and experience with utilization review processes. Familiarity with case management software, medical coding systems, and compliance with regulatory requirements such as NCQA or URAC is typically expected. Leadership, decision-making, and communication skills are crucial for effectively guiding teams and collaborating with providers. These competencies ensure efficient care coordination, regulatory compliance, and high-quality patient outcomes in a complex healthcare environment.

How does a manager in Aetna Utilization Review typically collaborate with clinical teams and other departments to ensure effective patient care?

A Manager of Aetna Utilization Review works closely with clinical teams, case managers, and other departments to coordinate care and ensure that medical services are necessary and meet established guidelines. This role often involves reviewing patient cases, providing guidance on coverage decisions, and facilitating clear communication between healthcare providers and insurance representatives. Regular meetings and case discussions help to resolve complex cases and optimize patient outcomes. Effective collaboration is key to balancing cost efficiency with quality care, and managers are expected to foster a supportive environment that encourages teamwork and continuous improvement.

What is the difference between Manager Aetna Utilization Review vs Utilization Review Nurse?

AspectManager Aetna Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or ANCC, and management experienceRegistered Nurse (RN) license, relevant certifications
Work EnvironmentSupervises utilization review teams, collaborates with healthcare providers, and manages case reviewsConducts patient case assessments, reviews medical records, and makes utilization decisions
Employer & Industry UsageCommonly employed by insurance companies like Aetna, healthcare organizations, and managed care firmsUsed within insurance companies, healthcare facilities, and third-party review organizations

The main difference is that the Manager Aetna Utilization Review oversees the review process and manages teams, while the Utilization Review Nurse focuses on conducting case assessments and medical reviews. Both roles require nursing credentials, but the manager position involves leadership and administrative responsibilities.

What are the most commonly searched types of Aetna Utilization Review jobs in Raleigh, NC?

The most popular types of Aetna Utilization Review jobs in Raleigh, NC are:

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For Manager Aetna Utilization Review jobs in Raleigh, NC, the most frequently searched job titles are:

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The top searched job categories for Manager Aetna Utilization Review jobs in Raleigh, NC are:

Manager Aetna Utilization Review jobs near you
Infographic showing various Manager Aetna Utilization Review job openings in Raleigh, NC as of August 2026, with employment types broken down into 86% Full Time, 13% Part Time, and 1% Contract. Highlights an 88% Physical, 2% Hybrid, and 10% Remote job distribution, with an average salary of $88,470 per year, or $42.5 per hour.

Utilization Review Nurse

Granville Health System

Oxford, NC

Per diem

Re-posted 13 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

Position Summary:

Conducts patient reviews as specified in review plan using screening criteria; identifies and documents actual and potential delays in services or treatment and works with departments and other providers to resolve problems; communicates to attending physician need for documentation for admission or continuation of hospitalization; refers cases that do not meet criteria to Director when needed. Screens all cases against high risk screens for discharge planning; conduct concurrent and retrospective reviews.

Qualifications:

North Carolina License as a Registered Nurse. Three years clinical nursing experience. One year utilization and review experience. Experience with MCG authorization criteria preferred. Knowledge of current nursing principles, techniques, procedures; knowledge of current utilization management criteria and standards. Excellent communication skills. Ability to work with physicians and hospital staff. Maintains professional knowledge and skills related to areas of responsibility. Self direction with the ability to work with minimal supervision and manage multiple tasks. Demonstrates understanding of variations in care of the following age groups - newborn, infant, child, adolescent, adult and geriatric.

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