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Utilization Management Assistant Jobs in Raleigh, NC

Cynet Health

RN - Case Manager

Chapel Hill, NC · On-site

Refer administrative tasks to the Care Management Assistant. Consult social workers and/or utilization managers as per departmental protocol. Benefits: We offer competitive benefits, including:

Duke Health

Behavioral Health Case Manager

Durham, NC · On-site

Work with Utilization Management partners to provide information and feedback that will enhance ... Conduct group sessions for patients focused on skill building/interactional skills. * Assist ...

Axelon

LTSS Service Care Manager

Raleigh, NC · On-site

... Assist in developing, assessing, and coordinating holistic care management activities Enable ... utilization management, or home health Proficiency in Microsoft Office Preferred Skills: Experience ...

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All JobsUtilization Management JobsUtilization Management Assistant JobsUtilization Management Assistant Jobs in Raleigh, NC

Utilization Management Assistant information

See Raleigh, NC salary details

$28.2K

$47K

$67.6K

How much do utilization management assistant jobs pay per year?

As of Jul 26, 2026, the average yearly pay for utilization management assistant in Raleigh, NC is $47,043.00, according to ZipRecruiter salary data. Most workers in this role earn between $40,800.00 and $47,100.00 per year, depending on experience, location, and employer.

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

To thrive as a Utilization Management Assistant, you need a solid understanding of healthcare processes, medical terminology, and administrative procedures, often supported by a high school diploma or associate's degree. Familiarity with electronic health records (EHR) systems, insurance verification tools, and Microsoft Office Suite is typically required. Strong organizational skills, attention to detail, and effective communication are crucial soft skills for managing documentation and collaborating with clinical teams. These skills ensure accurate data handling, efficient workflow, and compliance with healthcare regulations, all of which are vital for successful utilization management operations.

What are some common challenges Utilization Management Assistants face when working with insurance pre-authorizations?

Utilization Management Assistants often encounter challenges such as navigating complex insurance requirements, meeting tight deadlines for pre-authorization requests, and communicating effectively with both healthcare providers and insurance representatives. Staying organized and detail-oriented is essential to ensure all documentation is accurate and submitted promptly. Additionally, adapting to frequent changes in insurance policies and maintaining strong problem-solving skills are key to overcoming these obstacles.

What is a Utilization Management Assistant?

A Utilization Management Assistant is a healthcare administrative professional who supports the utilization management team by handling clerical tasks, coordinating communications, and organizing patient documentation. They often help ensure that medical services are used efficiently and that insurance requirements are met by gathering information, processing authorizations, and maintaining records. This role is essential in facilitating collaboration between healthcare providers, insurance companies, and patients, ultimately helping to optimize the quality and cost-effectiveness of patient care.
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 cities near Raleigh, NC are hiring for Utilization Management Assistant jobs? Cities near Raleigh, NC with the most Utilization Management Assistant job openings:
Utilization Management Assistant jobs near you
Infographic showing various Utilization Management Assistant job openings in Raleigh, NC as of July 2026, with employment types broken down into 1% As Needed, 77% Full Time, 19% Part Time, 1% Temporary, and 2% Contract. Highlights an 97% Physical, 1% Hybrid, and 2% Remote job distribution, with an average salary of $47,043 per year, or $22.6 per hour.
UM Clinical Specialist RN-Physical Health (Full-time Remote, NC Based)

UM Clinical Specialist RN-Physical Health (Full-time Remote, NC Based)

Alliance

Morrisville, NC • On-site, Remote

$68K - $86K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

This job post has expired 1 day ago. Applications are no longer accepted.

Job description

The Utilization Management (UM) Clinical Specialist RN for physical health (PH) independently assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services, monitors consumer treatment through ongoing and continuous review to ensure that services are delivered based on consumer need and established clinical guidelines, and identifies and follows-up on clinical cases of concern and high-risk/special needs consumers to ensure enrollees are linked to appropriate treatment resources. The UM Clinical Specialist RN - PH may represent the unit in cross agency collaborative needs.
This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to one of the offices for onsite team meetings as needed.
Responsibilities & Duties
Assesses the medical necessity of services
  • Independently conduct medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
  • Ensure authorized services address appropriate service needs, intensity of service outcomes, and alternatives for consumers
  • Provide a consistent application of medical necessity criteria for physical health services that promotes a holistic review of the member's needs
  • Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts
  • Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards
  • Notify members of adverse benefit determinations while preserving members' Due Process rights
  • Ensure compliance with performance measures outlined within all accrediting body standards
  • Perform other related duties as required by the immediate supervisor or other designated Alliance Health administrators

Compliance
  • Comply with utilization management and quality improvement policies and procedures, utilization review laws and regulations, state standards
  • Comply with Utilization Management Department focus on timeliness, effectiveness, quantity, quality, and cost of services for eligible enrollees

Coordinate and Implement UM Processes
  • Participate in the integration of the department and its functions into the organization's primary mission
  • Take part in the Utilization Management Department collaboration to ensure an integrated department with Physical Health and Behavioral Health

Collaborate with other departments
  • Monitor for undesirable performance or deviations of practice standards that may have a negative impact on consumers.
  • Respond through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO.
  • Maintain open, timely communication with staff, providers, community agencies and other stakeholders

Minimum Requirements
Education & Experience
Graduation from a State accredited school of nursing or an Associate's Degree in Nursing from an accredited and five years of experience with five (5) years nursing experience
OR
Bachelor's degree in Nursing from an accredited college/university and three (3) years of nursing experience
Special Requirement-
Current, active, and unrestricted North Carolina clinical license as a Registered Nurse, or a compact license
Preferred Experience:
Experience in Utilization Management
Knowledge, Skills, & Abilities
  • Knowledge of physical health and co-morbid health conditions
  • Knowledge of diagnostic treatment guidelines/protocols, level of care criteria
  • Proficient in the use of computer and multiple software programs.
  • Written and oral communication skills
  • Ability to interact with a wide variety of individuals and handle complex and confidential sensitive situations.
  • Knowledge of Utilization Management managed care principles and strategies
  • Ability to analyze effectiveness of processes and adjust developed processes.
  • Knowledge of and experience in acute clinical utilization review
  • Knowledge of Authorization/re-authorization Utilization Management standards
  • Knowledge of related duties in the delivery of patient care, management of patient care providers, or project management in a healthcare environment
  • Ability to lead, delegate and problem solve
  • Ability to develop and document workflows
  • Ability to assist appeal efforts when medical care is denied by various payor entities in a timely fashion.
  • Knowledge of and experience with NCQA

Employment for this position is contingent upon a satisfactory background, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range
$68,227-$86,990/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
  • Medical, Dental, Vision, Life, Long Term Disability
  • Generous retirement savings plan
  • Flexible work schedules including hybrid/remote options
  • Paid time off including vacation, sick leave, holiday, management leave
  • Dress flexibility

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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