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Rn Utilization Management Jobs in Raleigh, NC (NOW HIRING)

Duke University

Utilization Manager

Durham, NC · On-site

Duke University Health System has 6000 + registered nurses * Quality of Life: Living in the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

Duke University Health System has 6000 + registered nurses * Quality of Life: Living in the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke University

Utilization Manager

Durham, NC · On-site

Duke University Health System has 6000 + registered nurses * Quality of Life: Living in the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC

Duke University Health System has 6000 + registered nurses * Quality of Life: Living in the ... Supports denials management by documenting activities related to denials adjudication according to ...

WakeMed

Care Coordinator, RN

Cary, NC · On-site

... federal, state and third party utilization management regulatory requirements. Department ... EOE Licensure Registered Nurse Required Education Graduate Nursing Required - And Bachelor's Degree ...

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All JobsRn Utilization Management JobsRn Utilization Management Jobs in Raleigh, NC

Rn Utilization Management information

See Raleigh, NC salary details

$37.9K

$87K

$158.4K

How much do rn utilization management jobs pay per year?

As of Jul 29, 2026, the average yearly pay for rn utilization management in Raleigh, NC is $86,979.00, according to ZipRecruiter salary data. Most workers in this role earn between $62,700.00 and $101,600.00 per year, depending on experience, location, and employer.

How does an RN Utilization Management professional typically collaborate with physicians and other healthcare team members?

RN Utilization Management professionals work closely with physicians, case managers, and insurance representatives to ensure patients receive appropriate, high-quality care while managing healthcare costs. They review patient records, communicate clinical findings, and may participate in interdisciplinary meetings to discuss care plans and discharge needs. Building strong relationships and maintaining open lines of communication with the care team is essential for timely authorizations and effective care coordination. This collaborative approach helps optimize patient outcomes and resource utilization.

How to make $150,000 as a nurse?

Registered nurses in utilization management can reach a $150,000 salary by gaining specialized certifications, such as Certified Case Manager (CCM), and accumulating several years of experience in the field. Working in high-demand healthcare settings, taking on leadership roles, or pursuing advanced education like a master's degree can also increase earning potential.

What does a utilization management RN do?

A utilization management RN reviews medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They collaborate with healthcare providers and insurance companies to ensure patient care aligns with guidelines and policies, often using electronic health records and clinical criteria. Certification in case management or utilization review is common in this role.

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

To thrive as an RN Utilization Management Nurse, you need a current RN license, strong clinical assessment skills, and experience in care coordination or case management. Familiarity with utilization review tools, electronic health records, and knowledge of insurance guidelines or InterQual/MCG criteria are typically required. Exceptional communication, critical thinking, and negotiation skills help facilitate collaboration among providers, payers, and patients. These abilities are crucial for ensuring appropriate resource use, compliance with regulations, and optimal patient outcomes.

How to get into utilization management as an RN?

To become an RN in utilization management, you typically need a valid nursing license and experience in clinical settings. Gaining knowledge of insurance policies, healthcare regulations, and utilization review processes is important, and some employers prefer or require certification such as the Certified Professional in Healthcare Quality (CPHQ) or Certified Utilization Review Professional (CURP). Developing strong analytical, communication, and documentation skills can also improve job prospects in this field.

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

AspectRn Utilization ManagementRn Case Management
CertificationsRN license, possibly certifications in utilization reviewRN license, case management certification often preferred
Work EnvironmentUtilization review departments, insurance companies, hospitalsCommunity clinics, hospitals, insurance companies
Primary FocusReviewing medical necessity and appropriateness of servicesCoordinating patient care and discharge planning

Both roles require an RN license, but Rn Utilization Management focuses on reviewing the necessity of services, while Rn Case Management emphasizes coordinating patient care. Understanding these differences helps professionals choose the right career path and employers.

How to make an extra $2000 a month as a nurse?

Rn Utilization Management professionals can increase income by taking on overtime, working per diem shifts, or pursuing additional certifications such as case management or insurance review. Some also supplement income through consulting, remote case reviews, or part-time roles in telehealth, leveraging their clinical expertise and utilization review skills.

What are RN Utilization Management nurses?

RN Utilization Management nurses are registered nurses who specialize in reviewing healthcare services to ensure patients receive appropriate and cost-effective care. They evaluate the necessity, efficiency, and quality of medical treatments and procedures, often working with insurance companies, hospitals, or healthcare organizations. Their responsibilities include reviewing patient records, coordinating with clinical staff, making coverage recommendations, and ensuring compliance with healthcare regulations. This role helps manage healthcare costs while maintaining high standards of patient care.
What are popular job titles related to Rn Utilization Management jobs in Raleigh, NC? For Rn Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Rn Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Rn Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Rn Utilization Management jobs? Cities near Raleigh, NC with the most Rn Utilization Management job openings:
Rn Utilization Management jobs near you
Infographic showing various Rn Utilization Management job openings in Raleigh, NC as of July 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, 1% Temporary, and 2% Contract. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $86,979 per year, or $41.8 per hour.
Utilization Management Nurse

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Posted 21 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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