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Remote Utilization Management Jobs in Raleigh, NC

Aprio

Senior Director, Resource Management

Raleigh, NC · On-site +1

$225K - $300K/yr

Analyze trends in utilization and availability to drive redeployment of team members across offices ... remote and hybrid options What's in it for you: - Working with an industry leader : Be part of a ...

IQVIA

Director, Remote Research Clinicians

Durham, NC · Remote

... operational management platforms. * Develop standards, metrics, reporting frameworks, and ... Evaluate workload, utilization, productivity, quality, and customer satisfaction metrics. * Support ...

IQVIA

Director, Remote Research Clinicians

Durham, NC · Remote

... operational management platforms. * Develop standards, metrics, reporting frameworks, and ... Evaluate workload, utilization, productivity, quality, and customer satisfaction metrics. * Support ...

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

Remote Utilization Management information

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$20

$41

$67

How much do remote utilization management jobs pay per hour?

As of Jul 21, 2026, the average hourly pay for remote utilization management 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.

How does a Remote Utilization Management professional typically collaborate with healthcare providers and insurance teams?

Remote Utilization Management professionals frequently interact with both healthcare providers and insurance teams through secure digital platforms, phone calls, and virtual meetings. They review patient records, assess the necessity of medical services, and communicate their recommendations or authorization decisions. Effective collaboration requires clear documentation, timely responses, and strong communication skills to ensure that care is both medically appropriate and cost-effective. While the work is often independent, regular coordination with interdisciplinary teams is essential for maintaining high-quality patient outcomes and adhering to regulatory standards.

What are the key skills and qualifications needed to thrive as a Remote Utilization Management Nurse, and why are they important?

Success as a Remote Utilization Management Nurse requires a registered nursing license, clinical experience, and strong knowledge of medical necessity criteria and insurance guidelines. Familiarity with utilization review software, electronic health records (EHRs), and case management systems is typically necessary. Exceptional communication, critical thinking, and organizational skills help professionals excel in evaluating cases and coordinating with providers remotely. These skills are crucial for ensuring appropriate care, cost-effective resource use, and regulatory compliance in a remote healthcare setting.

What is remote utilization management?

Remote utilization management is a process in which healthcare professionals, such as nurses or case managers, review and assess the necessity, efficiency, and appropriateness of medical services—often from a remote location. These professionals typically work for insurance companies, hospitals, or healthcare organizations to ensure that patients receive the right care while controlling costs. By working remotely, they use electronic health records, phone calls, and other digital tools to collaborate with providers and patients. This role helps improve healthcare quality and cost-effectiveness while allowing employees flexible work arrangements.

What is the difference between Remote Utilization Management vs Remote Case Management?

AspectRemote Utilization ManagementRemote Case Management
CredentialsRN, LPN, or licensed healthcare professionalsRN, LPN, or social workers
Work EnvironmentHealthcare facilities, insurance companies, telehealthHealthcare providers, insurance, community agencies
Industry UsageInsurance, healthcare, telehealthHealthcare, social services, insurance
Primary FocusReviewing medical necessity, authorizationsCoordinating patient care, support services

Remote Utilization Management primarily involves reviewing medical necessity and authorizations, while Remote Case Management focuses on coordinating patient care and support services. Both roles require healthcare credentials and are used within healthcare and insurance industries, but they serve different functions in patient care and resource allocation.

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 Remote Utilization Management jobs in Raleigh, NC? For Remote Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Remote Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Remote Utilization Management jobs? Cities near Raleigh, NC with the most Remote Utilization Management job openings:
Remote Utilization Management jobs near you
Utilization Management Nurse

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • On-site, Remote

Full-time

Posted 14 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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