ZipRecruiter

Log In

2

Remote 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 ...

next page

Showing results 1-20

All JobsUtilization Review Nurse JobsRemote Utilization Review Nurse JobsRemote Utilization Review Nurse Jobs in Raleigh, NC

Remote Utilization Review Nurse information

See Raleigh, NC salary details

$20

$41

$67

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

As of Sep 7, 2026, the average hourly pay for remote 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 utilization review nurse?

A Remote Utilization Review Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments, typically from a remote location such as their home. They review patient medical records, apply clinical guidelines, and collaborate with providers and insurance companies to ensure patients receive appropriate care while managing healthcare costs. This role often involves making coverage determinations, conducting pre-authorizations, and participating in appeals processes. Remote Utilization Review Nurses play a critical role in improving patient outcomes and resource allocation within the healthcare system.

What does a remote utilization review nurse do?

As a remote utilization nurse, your duties are to work from home or a remote location to review patient medical records and prepare a range of paperwork for different types of actions a hospital or health care provider can take. Your responsibilities are to determine patient coverage, carry out denial of service authorizations, and negotiate different treatment options and hospital stay length for patients. You rely on your knowledge of treatment options and diseases to determine the level of appropriate care for a patient. Because you telecommute, you also need good technical skills.

What are the key skills and qualifications needed to thrive as a remote utilization review nurse?

To thrive as a Remote Utilization Review Nurse, you need a current RN license, clinical experience, and a solid understanding of medical necessity criteria and healthcare regulations. Familiarity with utilization management software, EHR systems, and certifications like CCM or URAC are highly valued. Strong analytical thinking, attention to detail, and effective communication skills enable success in evaluating clinical documentation and collaborating with providers remotely. These skills and qualifications are essential to ensure efficient, compliant care decisions that optimize patient outcomes and resource use.

How does a remote utilization review nurse collaborate with physicians and other healthcare team members while working remotely?

As a Remote Utilization Review Nurse, collaboration with physicians, case managers, and other healthcare professionals is primarily conducted through secure digital platforms such as email, video conferencing, and electronic health record systems. Effective communication is essential to discuss patient care plans, clarify medical necessity, and ensure compliance with utilization policies. Nurses in this role often participate in virtual meetings or case conferences to present findings and recommendations. Building strong working relationships remotely requires proactive communication, responsiveness, and familiarity with digital collaboration tools.

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

AspectRemote Utilization Review NurseRemote Case Manager
CertificationsRN license, possibly CCM or UR certificationsRN license, CCM or case management certifications
Work EnvironmentHealthcare facilities, insurance companies, telehealthInsurance companies, healthcare organizations, telehealth
Job FocusReview medical necessity, approve or deny servicesCoordinate patient care, arrange services, discharge planning

Remote Utilization Review Nurses primarily evaluate medical necessity for services, while Remote Case Managers coordinate patient care and discharge planning. Both roles require nursing credentials and work in healthcare or insurance settings, but their core responsibilities differ. Understanding these distinctions helps job seekers find the best fit for their skills and career goals.

More about Remote Utilization Review Nurse jobs

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

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

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

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

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

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

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

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

Remote Utilization Review Nurse jobs near you
Infographic showing various Remote Utilization Review Nurse job openings in Raleigh, NC as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 12% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 2% Hybrid, and 11% 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.
 

Powered by JazzHR

nQSfGpNUXN