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Remote Utilization Review Nurse Jobs in Raleigh, NC

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Network Administrator

Durham, NC · Remote

... Remote services/monitoring, Backup maintenance, EndPoint Hardware/Software, Wireless infrastructures, Vendor management. HeavySecurity emphasis. Collect/review network utilization reports: Debug ...

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Remote Utilization Review Nurse information

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$20

$41

$67

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

As of Aug 18, 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.

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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:

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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, 82% Full Time, 13% Part Time, 3% Contract, and 1% Nights. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution, with an average salary of $85,486 per year, or $41.1 per hour.

Senior Data Analyst, Clinical Programs

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Medical, Vision

Re-posted 27 days ago

Job description

About The Role
The Senior Data Analyst, Clinical Programs will be an analytically driven team player, responsible for understanding business needs and objectives, eliciting requirements from stakeholders, and analyzing data and processes to identify opportunities for improvement.  This role will support BHPS Clinical Programs, Utilization Management, Complex Case Management, and Population Health Management. In this role, you will be challenged to think creatively while developing actionable insights to inform client and program strategy.
*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, readmissions, preventable hospitalizations, ER utilization)  
  • Develop statistical models that deliver meaningful insights on cost, utilization and clinical outcomes based on various data sources.
  • Develop algorithms for stratifying populations and identifying high-risk members.
  • Leverage Predictive Analytics to measure the performance (ROI) of Disease Management and other Medical Management programs.
  • Conduct prospective savings analyses in support of clinical program initiatives.
  • Build and maintain client-facing reports, dashboards, and analyses.
  • Develop actionable data insights and advise on client strategy
  •  Participate in program performance review presentations with clinical program managers, client account managers, and external clients, as needed.
  • Manage internal and external client requests and timelines to ensure timely delivery.
  • Collaborate with Medical Management to provide ongoing support.
Essential Qualifications
  • Bachelors' degree required, preferably in Mathematics, Statistics, Finance, Actuarial Science, Data Science, or related field.
  • 5-7 years of experience in healthcare analytics, preferably in a managed care setting.
  • Proficiency in SQL and Microsoft SQL Server Suite of Products (SSMS) required.
  • Proficiency in MS Excel required.
  • Advanced data analysis, financial modeling, and predictive analytics skills.
  • Experience with clinical program evaluation and outcomes reporting. 
  • Experience with health plan performance reporting and cost and utilization analysis.
  • Experience with developing client-facing reports.
  • Experience with Business Intelligence applications and DAX functions (PowerPivot, Power BI, Tableau).
  • Ability to explain technical concepts to a non-technical audience .
  • Ability to effectively manage and prioritize several concurrent projects.
  • Excellent oral and written communications skills.
  • Experience with Payer Care Management platforms (i.e. ZeOmega) a plus.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
JOB ALERT FRAUD:  We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

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