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Remote Cvs Utilization Management Nurse Jobs in Raleigh, NC

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Remote Cvs Utilization Management Nurse information

See Raleigh, NC salary details

$20

$41

$67

How much do remote cvs utilization management nurse jobs pay per hour?

As of Aug 3, 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?

AspectRemote Cvs Utilization Management NurseRemote Cvs Case Manager
CredentialsRN license, certifications in utilization reviewRN license, case management certification
Work EnvironmentUtilization review teams, insurance companiesPatient advocacy, care coordination teams
Employer & IndustryHealth insurance, managed care organizationsHealth 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:
Remote Cvs Utilization Management Nurse jobs near you

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Posted 26 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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