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Manager Aetna Utilization Review Jobs in Raleigh, NC

Evolent

Physician Reviewer-Radiology (Full-Time)

Raleigh, NC · On-site

$95 - $96/hr

  • Medical

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a ... Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ...

Evolent

Physician Reviewer-Radiology (Part Time)

Raleigh, NC · On-site

$95 - $100/hr

  • Medical

As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a ... Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ...

Elevance Health

Prior Authorization Clinical Pharmacist

Durham, NC · On-site

$114K - $136K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

This role supports key clinical pharmacy programs, including Drug Utilization Review (DUR), Drug Information Services (DIS), and formulary management. How you will make an impact: * Researches and ...

UNC Medical Center

RN - Case Manager

Chapel Hill, NC · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

The role promotes continuity of care and cost-effectiveness through the integration of case management, utilization review, and discharge planning. The Care Manager must be a highly organized ...

American Traveler

Travel RN Care Manager

Chapel Hill, NC · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

Travel RN - Case Management/Utilization Review - Case Management About American Traveler With over 25 years of experience, American Traveler has established a reputation for outstanding customer ...

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Showing results 21-40

All JobsAetna Utilization Review JobsManager Aetna Utilization Review JobsManager Aetna Utilization Review Jobs in Raleigh, NC

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 Aug 16, 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 1% As Needed, 82% Full Time, 15% Part Time, and 2% Contract. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $88,470 per year, or $42.5 per hour.

Utilization Manager PRN 2 shifts of 8 hours a month

Duke University

Durham, NC • On-site

Per diem

Posted 12 days ago

Duke University rating

6.7

Company rating: 6.7 out of 10

Based on 55 frontline employees who took The Breakroom Quiz

486th of 618 rated colleges and universities

Job description

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.
Duke Nursing Highlights:
  • Duke University Health System is designated as a Magnet organization
  • Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
  • Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
  • Duke University Health System has 6000 + registered nurses
  • Quality of Life: Living in the Triangle!
  • Relocation Assistance (based on eligibility)

2 shifts of 8 hours a month
Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation that supports the medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team to address, understand, and mitigate excess/avoidable days. Serves as primary source of consultation for issues related to patient class (status) determination.
Work Performed
  • Validates authorization for all bedded patients and commercial initiatives. payer authorization within the contractual timeframe at time of presentation, every third day or as needed (e.g. ED, Direct Admit, Transfers).
  • Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary.
  • Conducts initial review and continued stay reviews as designated in UM plan.
  • Reviews records for medical necessity and collaborates with physician (s) and members of the care team to validate information.
  • Establishes and communicates estimated LOS and expected discharge date using GMLOS.
  • Utilizes an evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician Advisor or appeals as necessary in accordance with the UM plan.
  • Facilitates mitigation of denials and peer to peer conversations.
  • Collaborates with CM, CSW, Physicians, and Care Team to enhance communication related to discharge planning and utilization management.
  • Ongoing collaboration with Case Manager to ensure that patient's condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care.
  • Confirms that orders reflect the patient's billing patient status in accordance with the UM plan. Partners with internal Physician Advisors, as well as compliance and revenue cycle partners, within the health system to a safeguard processes and expected outcomes.
  • Provides formal and informal education to physicians and the healthcare team to improve processes and outcomes related to utilization review and compliance with utilization management plan.
  • Gives feedback as requested to enhance negotiations with payors.
  • Develops and maintains positive relationships with customers internal and external to Duke Health System.
  • Maintains effective communication with health care team members related to care coordination and utilization management.
  • Contributes to a positive working environment and performs other duties as assigned/directed to enhance the overall efforts for the organization.
  • Actively participates in a hospital committee.
  • Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines for all short-stay Medicare inpatients and outpatients (DUH), all observation encounters, all combined/segmental billing encounter questions, and any encounter sent to the UM MCA from PRMO for patient status/post-bill medical necessity denials/coding questions. Reviews and, when appropriate, completes as written appeal for post-bill regulatory agency and Medicare advantage medical necessity audits.
  • Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM screening and assessment for high-risk, potential readmits, and admitted patient encounters.
  • Collaborate with ED treatment team to prevent inappropriate admissions by facilitating community referrals and making post-dc arrangements, as appropriate. Works collaboratively with inpatient case management to support transitions from ED to inpatient.

Knowledge, Skills and Abilities
  • Basic computer proficiency required
  • Ability to become proficient in the navigation and interpretation of an electronic health record.
  • Work effectively in a self-directed role, multi-task, capable of daily problem-solving complex issues.
  • Excellent written and verbal skills
  • Basic proficiency in the use of Microsoft Word, Power Point and Excel

Level Characteristics
N/A
Minimum Qualifications
Education
BSN required
Experience
Minimum of three years recent acute clinical practice or related health care experience.
Degrees, Licensures, Certifications
Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire. BSN required and must have current or compact RN licensure in state of NC. BLS certification required.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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About Duke University

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Duke is regarded as one of America's leading research universities. Located in Durham, North Carolina, Duke is positioned in the heart of the Research Triangle, which is ranked annually as one of the best places in the country to work and live. Duke has more than 15,000 students who study and conduct research in its 10 undergraduate, graduate, and professional schools. With about 40,000 employees, Duke is the third largest private employer in North Carolina, and it now has international programs in more than 150 countries.

Industry

Colleges, universities, and professional schools and hospitals

Company size

10,000+ Employees

Headquarters location

Durham, NC, US

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