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Manager Aetna Utilization Review Jobs in Raleigh, NC

The Emily Program

Admissions Manager

Durham, NC · On-site

$80K - $90K/yr

Collaborate cross-functionally with clinical, medical, utilization review, and operational teams to ... Experience managing operational metrics, workflow coordination, and performance accountability ...

Omega Solutions Inc

Pharmacist

Raleigh, NC · On-site

... Management (PBM) Solution. The PBM Business Integration Specialist, as a Business Subject Matter ... Utilization Review (DUR) and pharmacy lock-in related processes, Behavioral health, and A+ kids ...

Senture

Medical Director

Raleigh, NC · Remote

... utilization management operation The Medical Director works collaboratively with organizational leadership, credentialing staff, peer reviewers, and regulatory stakeholders to ensure provider ...

Senture

Medical Director

Raleigh, NC · On-site

... utilization management operation The Medical Director works collaboratively with organizational leadership, credentialing staff, peer reviewers, and regulatory stakeholders to ensure provider ...

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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 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:

What are popular job titles related to Manager Aetna Utilization Review jobs in Raleigh, NC?

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

What job categories do people searching Manager Aetna Utilization Review jobs in Raleigh, NC look for?

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.

Prior Authorization Clinical Pharmacist

Elevance Health

Durham, NC

$114K - $136K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 5 days ago

Elevance Health rating

7.5

Company rating: 7.5 out of 10

Based on 354 frontline employees who took The Breakroom Quiz

217th of 315 rated insurance

Job description

Prior Authorization Clinical Pharmacist

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Prior Authorization Clinical Pharmacist is responsible for evaluating and managing the selection and utilization of pharmaceuticals to ensure safe, effective, and cost-efficient medication use. 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 synthesizes detailed clinical data related to pharmaceuticals.

  • Prepares and presents therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee.

  • May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with internal stakeholders or health plan medical directors as needed.

  • Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.

  • Prepares information for network physicians.

  • Prepares and presents therapeutic class reviews and drug monographs to the Pharmacy and Therapeutics (P&T) Committee.

  • Provides clinical guidance for therapeutic interventions, dosage conversions, and evidence-based medication use.

  • Develops and communicates drug information and recommendations to network physicians and clinical teams.

Minimum Requirements:

  • Requires BA/BS in Pharmacy.

  • Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.

  • Requires a registered pharmacist.

  • Current unrestricted Pharmacist license in applicable state(s) required.

  • For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

Preferred Skills, Capabilities and Experiences:

  • Active, unrestricted license to practice pharmacy as a Registered Pharmacist (RPh) in the state of Kansas highly preferred.

  • PharmD preferred.

  • PBM experience preferred.

  • Prior Authorization experience preferred.

  • Specialty Medication experience preferred.

Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

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About Elevance Health

Sourced by ZipRecruiter

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Indianapolis, IN, US

Year founded

2004

Social media

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