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Remote Anthem Utilization Review Nurse Jobs in Raleigh, NC

Senture

Medical Director

Raleigh, NC · Remote

While this position allows remote work, the individual must reside within the state of North ... Minimum three (3) years of experience supporting policy interpretation, utilization review ...

Centene

Psychologist Reviewer

Durham, NC · On-site +1

$87K - $157K/yr

Centene is Hiring - Remote Psychologist Reviewers (ABA) Centene is seeking Remote Psychologist ... Interact with network practitioners to provide education on best practice models and utilization ...

IQVIA

Director, Remote Research Clinicians

Durham, NC · Remote

Review quality metrics, issue trends, audit findings, and operational performance indicators to ... Evaluate workload, utilization, productivity, quality, and customer satisfaction metrics. * Support ...

IQVIA

Director, Remote Research Clinicians

Durham, NC · Remote

Review quality metrics, issue trends, audit findings, and operational performance indicators to ... Evaluate workload, utilization, productivity, quality, and customer satisfaction metrics. * Support ...

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All JobsAnthem Utilization Review Nurse JobsRemote Anthem Utilization Review Nurse JobsRemote Anthem Utilization Review Nurse Jobs in Raleigh, NC

Remote Anthem Utilization Review Nurse information

See Raleigh, NC salary details

$20

$41

$67

How much do remote anthem utilization review nurse jobs pay per hour?

As of Sep 8, 2026, the average hourly pay for remote anthem utilization review nurse in Raleigh, NC is $41.10, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.21 per hour, depending on experience, location, and employer.

What is a Remote Anthem Utilization Review Nurse?

A Remote Anthem Utilization Review Nurse is a registered nurse who works from home to review medical cases and claims for Anthem, a major health insurance company. Their primary role is to assess whether the healthcare services provided to members are medically necessary and align with Anthem’s policies and guidelines. They analyze patient records, collaborate with healthcare providers, and ensure that the care given is appropriate and cost-effective. By working remotely, these nurses use secure digital platforms to perform their duties, offering flexibility while maintaining high standards of care review.

What are the key skills and qualifications needed to thrive as a Remote Anthem Utilization Review Nurse?

To thrive as a Remote Anthem Utilization Review Nurse, you need a valid RN license, strong clinical judgment, and experience in utilization management or case review. Familiarity with medical management software, electronic health records, and accreditation standards such as NCQA or URAC is typically required. Excellent communication, critical thinking, and time management skills are essential for effective collaboration and decision-making in a virtual environment. These competencies ensure accurate reviews, regulatory compliance, and efficient care coordination for Anthem members.

What are some common challenges faced by Remote Anthem Utilization Review Nurses, and how can they be managed?

Remote Anthem Utilization Review Nurses often encounter challenges such as balancing high caseloads, navigating complex insurance guidelines, and maintaining effective communication with healthcare providers and patients from a distance. Staying organized and up-to-date with payer policies can help manage workload efficiently. Using secure communication platforms and participating in regular virtual team meetings also aids in building collaboration and ensuring accurate, timely reviews. Proactively seeking clarification on ambiguous cases and utilizing available support resources can further help overcome day-to-day obstacles in this remote role.

What is the difference between Remote Anthem Utilization Review Nurse vs Remote Case Manager?

AspectRemote Anthem Utilization Review NurseRemote Case Manager
CredentialsRN license, certifications in utilization reviewRN or social work license, case management certification
Work EnvironmentHealthcare insurance, utilization review teamsHealthcare providers, insurance companies, patient advocacy
Employer & IndustryHealth insurance companies like Anthem, healthcare industry

Remote Anthem Utilization Review Nurses focus on reviewing medical necessity and appropriateness of care for insurance claims, primarily within insurance companies. Remote Case Managers coordinate patient care, discharge planning, and resource management across healthcare settings. While both roles require healthcare knowledge and RN credentials, utilization review nurses specialize in insurance review processes, whereas case managers focus on patient care coordination.

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

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

What are popular job titles related to Remote Anthem Utilization Review Nurse jobs in Raleigh, NC?

For Remote Anthem Utilization Review Nurse jobs in Raleigh, NC, the most frequently searched job titles are:

What job categories do people searching Remote Anthem Utilization Review Nurse jobs in Raleigh, NC look for?

The top searched job categories for Remote Anthem Utilization Review Nurse jobs in Raleigh, NC are:

What cities near Raleigh, NC are hiring for Remote Anthem Utilization Review Nurse jobs?

Cities near Raleigh, NC with the most Remote Anthem Utilization Review Nurse job openings:

Remote Anthem Utilization Review Nurse jobs near you
Infographic showing various Remote Anthem Utilization Review Nurse job openings in Raleigh, NC as of August 2026, with employment types broken down into 88% Full Time, 7% Part Time, and 5% Contract. Highlights an 100% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted 2 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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