Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Utilization Manager
Durham, NC · On-site
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
... management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines ...
Compliance UM Nurse (Wed - Sun)
Raleigh, NC · On-site
Medical
Dental
Vision
Life
Retirement
PTO
... UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health?utilization?management experience for a health plan?? * Effective ...
Compliance UM Nurse (Wed - Sun)
Raleigh, NC · On-site
Medical
Dental
Vision
Life
Retirement
PTO
... UM auditing experience in a traditional Quality or Compliance role at a health plan OR one (1) or more years of home health?utilization?management experience for a health plan?? * Effective ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
Director, Outbound Transportation-Retail
Raleigh, NC · On-site
$150 - $230/hr
Experience in financial management, including freight auditing.Experience managing third-party ... Ability to improve backhaul utilization.Experience managing fleet vehicle acquisition, deployment ...
Director, Outbound Transportation-Retail
Raleigh, NC · On-site
$150 - $230/hr
Experience in financial management, including freight auditing.Experience managing third-party ... Ability to improve backhaul utilization.Experience managing fleet vehicle acquisition, deployment ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
Experience in financial management, including freight auditing. * Experience managing third-party ... Ability to improve backhaul utilization. * Experience managing fleet vehicle acquisition ...
When requested, interfaces with external and third party auditors; prepares and defends contract ... Management Or Accounting Required - With College Courses Finance Required - And Master's Degree ...
When requested, interfaces with external and third party auditors; prepares and defends contract ... Management Or Accounting Required - With College Courses Finance Required - And Master's Degree ...
Director, Managed Care Contracting
Raleigh, NC · On-site
$95 - $130/hr
When requested, interfaces with external and third‑party auditors; prepares and defends contract ... are Management or Accounting Required - With College Courses in Finance Required - And Master ...
Director, Managed Care Contracting
Raleigh, NC · On-site
$95 - $130/hr
When requested, interfaces with external and third‑party auditors; prepares and defends contract ... are Management or Accounting Required - With College Courses in Finance Required - And Master ...
Customer Success Manager
Apex, NC · On-site
Medical
Life
Retirement
PTO
... data, activity, utilization, trends, analysis, health, status, risks, and recommendations ... Proactive management of operational runbook for assigned accounts * Auditing the performance of the ...
Customer Success Manager
Apex, NC · On-site
Medical
Life
Retirement
PTO
... data, activity, utilization, trends, analysis, health, status, risks, and recommendations ... Proactive management of operational runbook for assigned accounts * Auditing the performance of the ...
Customer Success Manager
Apex, NC · On-site
$90K - $130K/yr
Medical
Life
Retirement
PTO
... data, activity, utilization, trends, analysis, health, status, risks, and recommendations ... Proactive management of operational runbook for assigned accounts * Auditing the performance of the ...
Quick apply
Customer Success Manager
Apex, NC · On-site
$90K - $130K/yr
Medical
Life
Retirement
PTO
... data, activity, utilization, trends, analysis, health, status, risks, and recommendations ... Proactive management of operational runbook for assigned accounts * Auditing the performance of the ...
Senior Revenue Accounting Manager
Raleigh, NC · On-site +1
Responsibilities Revenue Team Leadership and Close Management * Lead a global revenue accounting ... auditors on all revenue matters. Technical Accounting and Policy * Leverage deep IFRS 15/ASC 606 ...
Quick apply
Senior Revenue Accounting Manager
Raleigh, NC · On-site +1
Responsibilities Revenue Team Leadership and Close Management * Lead a global revenue accounting ... auditors on all revenue matters. Technical Accounting and Policy * Leverage deep IFRS 15/ASC 606 ...
EHS Application Admin
Raleigh, NC · On-site
Application deployment concepts including utilization of multiple application or system ... least privilege, auditing, logging, and permissions management. * Information Technology ...
EHS Application Admin
Raleigh, NC · On-site
Application deployment concepts including utilization of multiple application or system ... least privilege, auditing, logging, and permissions management. * Information Technology ...
... the Facility Manager, Director of Nursing and/or Charge Registered Nurse, utilizing standard ... Complies with all data collection and auditing activities. * Maintains facility environmental ...
... the Facility Manager, Director of Nursing and/or Charge Registered Nurse, utilizing standard ... Complies with all data collection and auditing activities. * Maintains facility environmental ...
Utilization Management Auditor information
See Raleigh, NC salary details
$15.19 - $18.55
14% of jobs
$21.32 is the 25th percentile. Wages below this are outliers.
$18.55 - $21.90
14% of jobs
$21.90 - $25.26
17% of jobs
The median wage is $27.10 / hr.
$25.26 - $28.61
11% of jobs
$28.61 - $31.97
8% of jobs
$31.97 - $35.33
6% of jobs
$37.84 is the 75th percentile. Wages above this are outliers.
$35.33 - $38.68
7% of jobs
$38.68 - $42.04
7% of jobs
$42.04 - $45.40
5% of jobs
$45.40 - $48.75
5% of jobs
$48.75 - $52.11
5% of jobs
$15
$31
$52
How much do utilization management auditor jobs pay per hour?
As of Aug 12, 2026, the average hourly pay for utilization management auditor in Raleigh, NC is $31.05, according to ZipRecruiter salary data. Most workers in this role earn between $21.73 and $39.47 per hour, depending on experience, location, and employer.
What is the difference between Utilization Management Auditor vs Utilization Review Nurse?
| Aspect | Utilization Management Auditor | Utilization Review Nurse |
|---|---|---|
| Credentials | Typically requires a nursing license, certifications like CCM or CUC | Licensed Registered Nurse (RN), often with additional certifications |
| Work Environment | Office-based, insurance companies, healthcare organizations | Hospital, clinics, insurance companies, often in clinical settings |
| Primary Focus | Auditing and reviewing utilization data for compliance and cost management | Assessing patient care needs and determining appropriate services |
While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.
What are some common challenges faced by utilization management auditors and how can they be addressed?
Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.
What is a utilization management auditor?
A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.
What are the key skills and qualifications needed to thrive as a utilization management auditor?
To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.
What are popular job titles related to Utilization Management Auditor jobs in Raleigh, NC? For Utilization Management Auditor jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Utilization Management Auditor jobs in Raleigh, NC look for? The top searched job categories for Utilization Management Auditor jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Utilization Management Auditor jobs? Cities near Raleigh, NC with the most Utilization Management Auditor job openings:
Full-time
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Duke University rating
6.7
Based on 55 frontline employees who took The Breakroom Quiz
485th of 618 rated colleges and universities
Job description
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.
Duke Nursing Highlights:
Every other weekend 8 hours 5 days a week
Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation that supports the medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team to address, understand, and mitigate excess/avoidable days. Serves as primary source of consultation for issues related to patient class (status) determination.
Work Performed
Knowledge, Skills and Abilities
Level Characteristics
N/A
Minimum Qualifications
Education
BSN required
Experience
Minimum of three years recent acute clinical practice or related health care experience.
Degrees, Licensures, Certifications
Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire. BSN required and must have current or compact RN licensure in state of NC. BLS certification required.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.
Duke Nursing Highlights:
- Duke University Health System is designated as a Magnet organization
- Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
- Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
- Duke University Health System has 6000 + registered nurses
- Quality of Life: Living in the Triangle!
- Relocation Assistance (based on eligibility)
Every other weekend 8 hours 5 days a week
Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation that supports the medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. Complies with current rules and regulatory requirements pertaining to utilization management. Initiates actions to obtain appropriate determinations. Collaborates with members of the healthcare team to address, understand, and mitigate excess/avoidable days. Serves as primary source of consultation for issues related to patient class (status) determination.
Work Performed
- Validates authorization for all bedded patients and commercial initiatives. payer authorization within the contractual timeframe at time of presentation, every third day or as needed (e.g. ED, Direct Admit, Transfers).
- Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary.
- Conducts initial review and continued stay reviews as designated in UM plan.
- Reviews records for medical necessity and collaborates with physician (s) and members of the care team to validate information.
- Establishes and communicates estimated LOS and expected discharge date using GMLOS.
- Utilizes an evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician Advisor or appeals as necessary in accordance with the UM plan.
- Facilitates mitigation of denials and peer to peer conversations.
- Collaborates with CM, CSW, Physicians, and Care Team to enhance communication related to discharge planning and utilization management.
- Ongoing collaboration with Case Manager to ensure that patient's condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care.
- Confirms that orders reflect the patient's billing patient status in accordance with the UM plan. Partners with internal Physician Advisors, as well as compliance and revenue cycle partners, within the health system to a safeguard processes and expected outcomes.
- Provides formal and informal education to physicians and the healthcare team to improve processes and outcomes related to utilization review and compliance with utilization management plan.
- Gives feedback as requested to enhance negotiations with payors.
- Develops and maintains positive relationships with customers internal and external to Duke Health System.
- Maintains effective communication with health care team members related to care coordination and utilization management.
- Contributes to a positive working environment and performs other duties as assigned/directed to enhance the overall efforts for the organization.
- Actively participates in a hospital committee.
- Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines for all short-stay Medicare inpatients and outpatients (DUH), all observation encounters, all combined/segmental billing encounter questions, and any encounter sent to the UM MCA from PRMO for patient status/post-bill medical necessity denials/coding questions. Reviews and, when appropriate, completes as written appeal for post-bill regulatory agency and Medicare advantage medical necessity audits.
- Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM screening and assessment for high-risk, potential readmits, and admitted patient encounters.
- Collaborate with ED treatment team to prevent inappropriate admissions by facilitating community referrals and making post-dc arrangements, as appropriate. Works collaboratively with inpatient case management to support transitions from ED to inpatient.
Knowledge, Skills and Abilities
- Basic computer proficiency required
- Ability to become proficient in the navigation and interpretation of an electronic health record.
- Work effectively in a self-directed role, multi-task, capable of daily problem-solving complex issues.
- Excellent written and verbal skills
- Basic proficiency in the use of Microsoft Word, Power Point and Excel
Level Characteristics
N/A
Minimum Qualifications
Education
BSN required
Experience
Minimum of three years recent acute clinical practice or related health care experience.
Degrees, Licensures, Certifications
Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire. BSN required and must have current or compact RN licensure in state of NC. BLS certification required.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
What Duke University employees say
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About Duke University
Sourced by ZipRecruiter
Duke is regarded as one of America's leading research universities. Located in Durham, North Carolina, Duke is positioned in the heart of the Research Triangle, which is ranked annually as one of the best places in the country to work and live. Duke has more than 15,000 students who study and conduct research in its 10 undergraduate, graduate, and professional schools. With about 40,000 employees, Duke is the third largest private employer in North Carolina, and it now has international programs in more than 150 countries.
Industry
Colleges, universities, and professional schools and hospitals
Company size
10,000+ Employees
Headquarters location
Durham, NC, US