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Senior Cvs Health Utilization Management Jobs in Raleigh, NC

Duke Health

Utilization Manager

Durham, NC

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

Duke University

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

Duke University

Utilization Manager

Durham, NC · On-site

Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team ...

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Senior Cvs Health Utilization Management information

See Raleigh, NC salary details

$30.1K

$77.5K

$113.7K

How much do senior cvs health utilization management jobs pay per year?

As of Sep 6, 2026, the average yearly pay for senior cvs health utilization management in Raleigh, NC is $77,544.00, according to ZipRecruiter salary data. Most workers in this role earn between $48,600.00 and $113,200.00 per year, depending on experience, location, and employer.

What is the difference between Senior Cvs Health Utilization Management vs Utilization Review Nurse?

AspectSenior Cvs Health Utilization ManagementUtilization Review Nurse
CredentialsRN license, certifications in case management or utilization reviewRN license, certifications in utilization review or case management
Work EnvironmentCorporate healthcare setting, insurance plans, managed careHospitals, clinics, insurance companies, managed care organizations
Employer & Industry UsageMajor healthcare providers, insurance companies, pharmacy benefit managersHospitals, insurance companies, healthcare facilities

Both roles involve reviewing patient cases to determine appropriate care and resource utilization. The Senior Cvs Health Utilization Management position typically involves more strategic oversight and coordination within CVS Health's managed care programs, while Utilization Review Nurses focus on direct case assessments and clinical reviews. Understanding these differences helps candidates align their skills with the right role in healthcare management.

What are the most commonly searched types of Cvs Health Utilization Management jobs in Raleigh, NC?

The most popular types of Cvs Health Utilization Management jobs in Raleigh, NC are:

What are popular job titles related to Senior Cvs Health Utilization Management jobs in Raleigh, NC?

For Senior Cvs Health Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:

What job categories do people searching Senior Cvs Health Utilization Management jobs in Raleigh, NC look for?

The top searched job categories for Senior Cvs Health Utilization Management jobs in Raleigh, NC are:

What cities near Raleigh, NC are hiring for Senior Cvs Health Utilization Management jobs?

Cities near Raleigh, NC with the most Senior Cvs Health Utilization Management job openings:

Senior Cvs Health Utilization Management jobs near you
Infographic showing various Senior Cvs Health Utilization Management job openings in Raleigh, NC as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 18% Part Time, and 5% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $77,544 per year, or $37.3 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted 10 hours 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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