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 ...
Quick apply
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 ...
Utilization Management Nurse
Chapel Hill, NC · On-site +1
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 ...
Utilization Management Nurse
Chapel Hill, NC · On-site +1
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 ...
Remote Registered Nurse (RN) Case Manager
Raleigh, NC · Remote
$50K/yr
Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case management or Clinical Trial Nurse experience, a plus. * Bachelor's degree preferred. * Remote work ...
Remote Registered Nurse (RN) Case Manager
Raleigh, NC · Remote
$50K/yr
Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case management or Clinical Trial Nurse experience, a plus. * Bachelor's degree preferred. * Remote work ...
Remote Registered Nurse (RN) Case Manager
Raleigh, NC · On-site +1
$50K/yr
Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case management or Clinical Trial Nurse experience, a plus. * Bachelor's degree preferred. * Remote work ...
Remote Registered Nurse (RN) Case Manager
Raleigh, NC · On-site +1
$50K/yr
Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case management or Clinical Trial Nurse experience, a plus. * Bachelor's degree preferred. * Remote work ...
... utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North ...
... utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North ...
This is a Remote role. Primary Responsibilities * Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates ...
Quick apply
This is a Remote role. Primary Responsibilities * Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates ...
Medical Director
Raleigh, NC · Remote
... plan, or utilization management operation The Medical Director works collaboratively with ... While this position allows remote work, the individual must reside within the state of North ...
Medical Director
Raleigh, NC · Remote
... plan, or utilization management operation The Medical Director works collaboratively with ... While this position allows remote work, the individual must reside within the state of North ...
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
UM Program Integrity Specialist (Full-time Remote, North Carolina Based)
Morrisville, NC · On-site +1
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
UM Program Integrity Specialist (Full-time Remote, North Carolina Based)
Morrisville, NC · On-site +1
... Utilization Management (UM) Training Plan that supports onboarding, role-specific education ... human services, nursing, social work, psychology, counseling, or a related healthcare, human ...
Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue ... Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ...
Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue ... Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ...
Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue ... Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ...
Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue ... Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ...
Psychologist Reviewer
Durham, NC · On-site +1
$87K - $157K/yr
... utilization management processes * Interact with the Medical Director, or designee, to discuss ... with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an ...
Psychologist Reviewer
Durham, NC · On-site +1
$87K - $157K/yr
... utilization management processes * Interact with the Medical Director, or designee, to discuss ... with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an ...
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... utilization, cost, quality, clinical, and operational data as appropriate. • Clean, validate ...
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... utilization, cost, quality, clinical, and operational data as appropriate. • Clean, validate ...
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... utilization, cost, quality, clinical, and operational data as appropriate. • Clean, validate ...
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... utilization, cost, quality, clinical, and operational data as appropriate. • Clean, validate ...
Financial Analyst I-Rate Specialist (Full Time, Remote, North Carolina Based)
Morrisville, NC · On-site +1
$61K - $78K/yr
... remote. While there is no expectation of being in the office routinely, they will be required to ... and Utilization Management Departments Improve reporting and input capabilities * Evaluate all ...
Financial Analyst I-Rate Specialist (Full Time, Remote, North Carolina Based)
Morrisville, NC · On-site +1
$61K - $78K/yr
... remote. While there is no expectation of being in the office routinely, they will be required to ... and Utilization Management Departments Improve reporting and input capabilities * Evaluate all ...
Case Manager Nurse Advocate- Raleigh area
Raleigh, NC · On-site +1
SYNERGY HEALTHCARE: Case Manager Nurse Advocate- Greater Raleigh Area Job Summary: We are seeking ... This opportunity allows for remote work so can be flexible on location. Minimal travel within the ...
Case Manager Nurse Advocate- Raleigh area
Raleigh, NC · On-site +1
SYNERGY HEALTHCARE: Case Manager Nurse Advocate- Greater Raleigh Area Job Summary: We are seeking ... This opportunity allows for remote work so can be flexible on location. Minimal travel within the ...
... ) to serve our patient population in the navigation, prevention and management of their health through continuous care programs like Remote Patient Monitoring and Chronic Care Management. Our team ...
Quick apply
... ) to serve our patient population in the navigation, prevention and management of their health through continuous care programs like Remote Patient Monitoring and Chronic Care Management. Our team ...
... ) to serve our patient population in the navigation, prevention and management of their health through continuous care programs like Remote Patient Monitoring and Chronic Care Management. Our team ...
... ) to serve our patient population in the navigation, prevention and management of their health through continuous care programs like Remote Patient Monitoring and Chronic Care Management. Our team ...
... remote work with travel of up to 25% . This role is ideal for an experienced RN with Clinical ... Support project management and Agile/Kanban workflows What We're Looking For: * Bachelor's Degree ...
Quick apply
... remote work with travel of up to 25% . This role is ideal for an experienced RN with Clinical ... Support project management and Agile/Kanban workflows What We're Looking For: * Bachelor's Degree ...
Remote Cvs Utilization Management Nurse information
See Raleigh, NC salary details
$20.80 - $25
2% of jobs
$25 - $29.21
9% of jobs
$32.09 is the 25th percentile. Wages below this are outliers.
$29.21 - $33.42
21% of jobs
The median wage is $36.82 / hr.
$33.42 - $37.62
23% of jobs
$37.62 - $41.83
13% of jobs
$45.10 is the 75th percentile. Wages above this are outliers.
$41.83 - $46.03
10% of jobs
$46.03 - $50.24
8% of jobs
$50.24 - $54.45
5% of jobs
$54.45 - $58.65
5% of jobs
$58.65 - $62.86
2% of jobs
$62.86 - $67.06
2% of jobs
$20
$41
$67
How much do remote cvs utilization management nurse jobs pay per hour?
As of Aug 30, 2026, the average hourly pay for remote cvs utilization management 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 the difference between Remote Cvs Utilization Management Nurse vs Remote Cvs Case Manager?
| Aspect | Remote Cvs Utilization Management Nurse | Remote Cvs Case Manager |
|---|---|---|
| Credentials | RN license, certifications in utilization review | RN license, case management certification |
| Work Environment | Utilization review teams, insurance companies | Patient advocacy, care coordination teams |
| Employer & Industry | Health insurance, managed care organizations | Health insurance, healthcare providers |
Both roles require RN licensure and related certifications, but the Utilization Management Nurse focuses on reviewing medical necessity and approving services, while the Case Manager emphasizes coordinating patient care and discharge planning. Understanding these differences helps job seekers find the right fit within the healthcare and insurance industries.
What are the most commonly searched types of Cvs Utilization Management Nurse jobs in Raleigh, NC?
The most popular types of Cvs Utilization Management Nurse jobs in Raleigh, NC are:
What are popular job titles related to Remote Cvs Utilization Management Nurse jobs in Raleigh, NC?
For Remote Cvs Utilization Management Nurse jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Remote Cvs Utilization Management Nurse jobs in Raleigh, NC look for?
The top searched job categories for Remote Cvs Utilization Management Nurse jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Remote Cvs Utilization Management Nurse jobs?
Cities near Raleigh, NC with the most Remote Cvs Utilization Management Nurse job openings:
Full-time
Re-posted 24 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.
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.
Powered by JazzHR
nQSfGpNUXN
About Brighton Health Plan Solutions
Sourced by ZipRecruiter