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Utilization Management Jobs in Raleigh, NC (NOW HIRING)

Duke University

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke University

Utilization Manager

Durham, NC

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

Duke Health

Utilization Manager

Durham, NC · On-site

... and utilization review outcomes with current rules and regulatory requirements. Supports the ... Supports denials management by documenting activities related to denials adjudication according to ...

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All JobsUtilization Management JobsUtilization Management Jobs in Raleigh, NC

Utilization Management information

See Raleigh, NC salary details

$37.9K

$87K

$158.4K

How much do utilization management jobs pay per year?

As of Aug 10, 2026, the average yearly pay for 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.

What are the key skills and qualifications needed to thrive in utilization management, and why are they important?

To thrive in Utilization Management, you need a strong understanding of healthcare procedures, insurance guidelines, and case review processes, usually backed by a clinical background such as RN, LPN, or allied health certification. Familiarity with medical management software, electronic health records (EHR), and utilization review tools like InterQual or MCG is often required. Excellent analytical thinking, attention to detail, and effective communication skills greatly enhance performance in this role. These competencies enable accurate assessment of medical necessity, ensure regulatory compliance, and support efficient, collaborative workflows between providers, insurers, and patients.

What is utilization management?

A Utilization Management (UM) job involves evaluating medical services to ensure they are necessary, cost-effective, and compliant with healthcare guidelines. Professionals in this field review patient care plans, authorize treatments, and collaborate with healthcare providers to optimize resource use. They work for insurance companies, hospitals, or healthcare organizations to balance quality care with cost control. Strong analytical skills and knowledge of medical policies are essential in this role.

What are the typical daily responsibilities of a utilization management professional?

As a Utilization Management professional, your day-to-day duties typically include reviewing patient admissions, authorizing ongoing treatment or procedures, assessing medical necessity, and ensuring services comply with insurance policies and industry guidelines. You will frequently collaborate with physicians, nurses, and insurance representatives to facilitate timely and appropriate care decisions while managing cost and quality. Documentation and communication play key roles as you help bridge the gap between clinical teams and payers. This role is often fast-paced, requires decisive action, and provides opportunities to have a direct impact on patient outcomes and organizational efficiency.

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 are popular job titles related to Utilization Management jobs in Raleigh, NC? For Utilization Management jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Utilization Management jobs in Raleigh, NC look for? The top searched job categories for Utilization Management jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Utilization Management jobs? Cities near Raleigh, NC with the most Utilization Management job openings:
Utilization Management jobs near you
Infographic showing various Utilization Management job openings in Raleigh, NC as of August 2026, with employment types broken down into 93% Full Time, and 7% Contract. Highlights an 67% In-person, and 33% Remote job distribution, with an average salary of $86,979 per year, or $41.8 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted 3 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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