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Utilization Management Physician Reviewer Jobs in Raleigh, NC

Duke Health

Utilization Manager

Durham, NC · On-site

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 ...

Duke Health

Utilization Manager

Durham, NC · On-site

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 ...

Duke University

Utilization Manager

Durham, NC · On-site

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 ...

Duke University

Utilization Manager

Durham, NC · On-site

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 ...

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All JobsUtilization Management Physician Reviewer JobsUtilization Management Physician Reviewer Jobs in Raleigh, NC

Utilization Management Physician Reviewer information

See Raleigh, NC salary details

$30.1K

$36.9K

$42.8K

How much do utilization management physician reviewer jobs pay per year?

As of Sep 2, 2026, the average yearly pay for utilization management physician reviewer in Raleigh, NC is $36,932.00, according to ZipRecruiter salary data. Most workers in this role earn between $33,000.00 and $40,800.00 per year, depending on experience, location, and employer.

What does a utilization management physician reviewer do?

A Utilization Management Physician Reviewer is a licensed physician who evaluates the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and hospital admissions. They review patient records and clinical information to ensure that care meets evidence-based guidelines and payer requirements. Their decisions help manage healthcare costs while ensuring patients receive necessary treatment. These professionals often work with insurance companies, hospitals, or managed care organizations.

What are the key skills and qualifications needed to thrive as a utilization management physician reviewer?

To thrive as a Utilization Management Physician Reviewer, you need a valid medical degree (MD or DO), clinical experience, and licensure, often supplemented by board certification. Familiarity with utilization review guidelines, InterQual or MCG criteria, and electronic health record (EHR) systems is typically required. Strong analytical thinking, attention to detail, and effective communication help reviewers collaborate with providers and interpret complex medical data. These skills are crucial to ensuring appropriate, cost-effective patient care while adhering to regulatory and payer requirements.

What are the typical challenges faced by a utilization management physician reviewer, and how can they be addressed?

Utilization Management Physician Reviewers often encounter the challenge of balancing clinical judgment with payer policies and guidelines. They must make objective decisions about medical necessity, which can sometimes conflict with providers' recommendations or patient expectations. Effective communication and staying current with evolving healthcare regulations are crucial to address these challenges. Additionally, collaborating closely with multidisciplinary teams helps ensure thorough, fair reviews and fosters a supportive work environment.

What is the difference between Utilization Management Physician Reviewer vs Utilization Management Nurse Reviewer?

AspectUtilization Management Physician ReviewerUtilization Management Nurse Reviewer
CredentialsMedical degree, medical license, often board-certifiedNursing license, RN certification, possibly case management certification
Work EnvironmentHospitals, insurance companies, healthcare organizationsInsurance companies, healthcare organizations, case management teams
Primary ResponsibilitiesReview medical necessity, approve or deny services, interpret clinical dataAssess patient records, review care plans, evaluate medical necessity from nursing perspective

While both roles involve reviewing healthcare services for appropriateness, the Utilization Management Physician Reviewer primarily makes decisions based on medical expertise and clinical judgment, whereas the Utilization Management Nurse Reviewer focuses on nursing assessments and care coordination. Both roles are essential in ensuring appropriate healthcare utilization within insurance and healthcare settings.

How to become a utilization management physician reviewer?

To become a utilization management physician reviewer, candidates typically need a medical degree, a valid medical license, and experience in clinical practice. Additional certifications such as board certification in a relevant specialty and knowledge of healthcare policies and coding can enhance qualifications. Familiarity with utilization review processes and documentation is also important.

What are popular job titles related to Utilization Management Physician Reviewer jobs in Raleigh, NC?

For Utilization Management Physician Reviewer jobs in Raleigh, NC, the most frequently searched job titles are:

What job categories do people searching Utilization Management Physician Reviewer jobs in Raleigh, NC look for?

The top searched job categories for Utilization Management Physician Reviewer jobs in Raleigh, NC are:

What cities near Raleigh, NC are hiring for Utilization Management Physician Reviewer jobs?

Cities near Raleigh, NC with the most Utilization Management Physician Reviewer job openings:

Utilization Management Physician Reviewer jobs near you
Infographic showing various Utilization Management Physician Reviewer job openings in Raleigh, NC as of August 2026, with employment types broken down into 10% As Needed, and 90% Full Time. Highlights an 80% In-person, 10% Hybrid, and 10% Remote job distribution, with an average salary of $36,932 per year, or $17.8 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted 26 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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