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Manager Utilization Management Jobs in Raleigh, NC

Duke University

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke University

Utilization Manager

Durham, NC

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Axelon

LTSS Service Care Manager

Raleigh, NC · On-site

Hospital CM, Home health, discharge planning, or long-term care experience Home health experience Required Skills: RN and/or LCSW Experience in physical hospital health, care management, utilization ...

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All JobsUtilization Management JobsManager Utilization Management JobsManager Utilization Management Jobs in Raleigh, NC

Manager Utilization Management information

See Raleigh, NC salary details

$37.9K

$88.5K

$162.8K

How much do manager utilization management jobs pay per year?

As of Jul 25, 2026, the average yearly pay for manager utilization management 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 are the key skills and qualifications needed to thrive as a Manager Utilization Management, and why are they important?

To thrive as a Manager Utilization Management, you need a thorough understanding of healthcare regulations, utilization review processes, and case management, often supported by a clinical degree (such as RN) and relevant experience. Familiarity with utilization management software, claims processing systems, and potentially certifications like CCM (Certified Case Manager) or ACM (Accredited Case Manager) is important. Strong leadership, analytical thinking, and effective communication help you guide teams and collaborate with providers and payers. These skills ensure efficient resource use, compliance, and quality patient care within managed care organizations.

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

AspectManager Utilization ManagementUtilization Review Nurse
CredentialsRN, often with management or utilization review certificationsRN, with certifications in utilization review or case management
Work EnvironmentSupervises teams, manages policies, oversees utilization review processesPerforms patient chart reviews, assesses medical necessity, collaborates with providers
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare organizations
Search & Comparison IntentYesYes

While both roles focus on utilization review, the Manager Utilization Management oversees teams and policies, ensuring efficient resource use, whereas the Utilization Review Nurse conducts patient-specific reviews to determine medical necessity. The manager role involves leadership and strategic planning, while the nurse role is more clinical and review-focused.

What are some common challenges faced by a Manager in Utilization Management, and how can they effectively address them?

Managers in Utilization Management often encounter challenges such as balancing quality patient care with cost containment, navigating evolving healthcare regulations, and managing diverse teams. To effectively address these issues, successful managers develop strong communication skills, stay updated on industry standards, and foster collaboration between clinical and administrative staff. Implementing robust training programs and utilizing data-driven decision-making can also help ensure compliance and improve overall team performance.

What does a Manager of Utilization Management do?

A Manager of Utilization Management oversees the process of evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead a team that reviews medical claims and care plans to ensure compliance with clinical guidelines and regulatory requirements. Their role often involves collaborating with physicians, nurses, insurance companies, and other stakeholders to optimize patient outcomes while managing healthcare costs. Additionally, they are responsible for implementing policies, training staff, and ensuring that utilization management activities align with organizational goals.
What are the most commonly searched types of Utilization Management jobs in Raleigh, NC? The most popular types of Utilization Management jobs in Raleigh, NC are:
What are popular job titles related to Manager Utilization Management jobs in Raleigh, NC? For Manager Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Manager Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Manager Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Manager Utilization Management jobs? Cities near Raleigh, NC with the most Manager Utilization Management job openings:
Manager Utilization Management jobs near you
Infographic showing various Manager Utilization Management job openings in Raleigh, NC as of July 2026, with employment types broken down into 92% Full Time, and 8% Part Time. Highlights an 77% In-person, and 23% Remote job distribution, with an average salary of $88,470 per year, or $42.5 per hour.
Utilization Management Nurse

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Posted 18 days ago

Job description

About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
•    Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
•    Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
•    Collaborates with healthcare partners to ensure timely review of services and care.
•    Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
•    Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
•    Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
•    Triages and prioritizes cases and other assigned duties to meet required turnaround times.
•    Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
•    Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
•    Duties as assigned.
Essential Qualifications
•    Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
•    Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
•    Must be able to work independently.
•    Must be detail oriented and have strong organizational and time management skills.
•    Adaptive to a high pace and changing environment- flexibility in assignment.
•    Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
•    Proficient in MCG and CMS criteria sets
•    Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
•    Working knowledge of URAC and NCQA.
•   2+ years’ experience in a UM team within managed care setting.
•   3+ years’ experience in clinical nurse setting preferred.
•   TPA Experience preferred.

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