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Remote Insurance Utilization Review Jobs in North Carolina

Sagility LLC

RN Utilization Management Reviewer

Concord, NC · Remote

$35 - $40/hr

Conducts timely clinical decision review for services requiring prior authorization in a variety of ... Life Insurance * Short-Term and Long-Term Disability * Flexible Spending Account * Life Assistance ...

Sagility

RN Utilization Management Reviewer

Concord, NC · Remote

$35 - $40/hr

Conducts timely clinical decision review for services requiring prior authorization in a variety of ... Life Insurance * Short-Term and Long-Term Disability * Flexible Spending Account * Life Assistance ...

Sagility

RN Utilization Management Reviewer

Concord, NC · Remote

$35 - $40/hr

Conducts timely clinical decision review for services requiring prior authorization in a variety of ... Life Insurance * Short-Term and Long-Term Disability * Flexible Spending Account * Life Assistance ...

Sagility LLC

RN Utilization Management Reviewer

Concord, NC · Remote

$35 - $40/hr

Conducts timely clinical decision review for services requiring prior authorization in a variety of ... Life Insurance * Short-Term and Long-Term Disability * Flexible Spending Account * Life Assistance ...

Encova Insurance

Nurse Case Manager

Concord, NC · On-site +1

$55K - $110K/yr

One year of experience in nurse case management, medical case management, utilization review ... Encova Insurance is an EOE/E-Verify employer. #LI-Hybrid#LI-MF1

Senture

Medical Director

Raleigh, NC · Remote

... utilization review, credentialing, claims resolution, or medical review functions within commercial and/or government-sponsored health insurance programs. * Demonstrated knowledge of NCQA ...

Centene

Psychologist Reviewer

Greensboro, 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 ...

Centene

Psychologist Reviewer

Wilmington, 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 ...

Centene

Psychologist Reviewer

Winston Salem, 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 ...

Centene

Psychologist Reviewer

Concord, 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 ...

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 ...

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Remote Insurance Utilization Review information

What is a remote insurance utilization review?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What skills and qualifications are needed for a remote insurance utilization review specialist?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

What are popular job titles related to Remote Insurance Utilization Review jobs in North Carolina?

For Remote Insurance Utilization Review jobs in North Carolina, the most frequently searched job titles are:

What job categories do people searching Remote Insurance Utilization Review jobs in North Carolina look for?

The top searched job categories for Remote Insurance Utilization Review jobs in North Carolina are:

What cities in North Carolina are hiring for Remote Insurance Utilization Review jobs?

Cities in North Carolina with the most Remote Insurance Utilization Review job openings:

Remote Insurance Utilization Review jobs near you
Infographic showing various Remote Insurance Utilization Review job openings in North Carolina as of August 2026, with employment types broken down into 1% As Needed, 71% Full Time, 17% Part Time, 7% Temporary, and 4% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution.

RN Utilization Management Reviewer

Concord, NC • Remote

Sagility LLC
Strategic Planning Consulting Services • 10K+ employees

4.6

Company rating: 4.6 out of 10

Based on 29 frontline employees who took The Breakroom Quiz

63rd of 72 rated call and contact centers

Paid breaks

Respectful managers

Uninterrupted breaks

Learn more about Sagility LLCexternal

$35 - $40/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 18 days ago

Job description

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

Job title:

RN Utilization Management Reviewer

Job Description:

We are currently hiring a talented RN, Utilization Management Reviewer. This role will be responsible in day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must hold a valid, current license issued by the Massachusetts Board of Registration in Nursing.

Key responsibilities:

  • Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH)
  • Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
  • Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
  • Provides decision-making guidance to clinical teams on service planning as needed
  • Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
  • Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
  • Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
  • Additional duties as requested by supervisor
  • Maintains knowledge of CMS, State and NCQA regulatory requirements

Education Requirements:

  • RN - Associate's Degree required, Bachelor's Degree preferred
  • RN, current license issued by the Massachusetts Board of Registration in Nursing
  • CCM (Certified Case Manager) a plus

Required Experience (must have):

  • 1 to 2 years Utilization Management experience.
  • 2 or more years working in a clinical setting

Desired Experience (nice to have):

  • 2 or more years of Home Health Care experience
  • 2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

  • Ability to complete assigned work in a timely and accurate manner
  • Knowledge of the Utilization management process
  • Ability to work independently

Desired Knowledge, Skills, Abilities & Language (nice to have):

  • Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity
  • Flexibility and understanding of individualized care plans
  • Ability to influence decision making
  • Strong collaboration and negotiation skills
  • Strong interpersonal, verbal, and written communication skills
  • Comfort working in a team-based environment
  • Knowledge of Medicare and Mass health services and benefits

Salary: $35.00 - $40.00 Hourly pending experience

Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekends

This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.

Sagility Offers Competitive Benefits Including:

  • Medical
  • Dental
  • Vision
  • Life Insurance
  • Short-Term and Long-Term Disability
  • Flexible Spending Account
  • Life Assistance Program
  • 401K with employer contribution
  • PTO and Sick Time
  • Tuition Reimbursement

Join our team, we look forward to talking with you!

An Equal Opportunity Employer/Vet/Disability

Location:

Work@Home USAUnited States of America

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