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Utilization Management Jobs in Raleigh, NC (NOW HIRING)

To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive ...

Appeals Pharmacist (Remote)

Raleigh, NC · On-site +1

$51 - $62.25/hr

Experience: Prior managed care or utilization management experience preferred - retail and hospital pharmacists with strong clinical and documentation skills are encouraged to apply. * Skills:

Work Experience/Direct knowledge of Utilization Management or Tapestry Utilization Management build * Strong desktop skills including Word, Excel, PowerPoint * Work Experience/Direct Knowledge of ...

Work Experience/Direct knowledge of Utilization Management or Tapestry Utilization Management build * Analytical/ Decision Making Responsibilities * Analytical ability to manage multiple projects and ...

Work Experience/Direct knowledge of Utilization Management or Tapestry Utilization Management build * Ability to work independently and collaborate as part of a team * Effective written and verbal ...

Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers. * Maintain timely documentation of assessment findings ...

Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers. * Maintain timely documentation of assessment findings ...

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Utilization Management information

See Raleigh, NC salary details

$37.9K

$87K

$158.4K

How much do utilization management jobs pay per year?

As of Jun 9, 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 the Utilization Management position, 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 a Utilization Management job?

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 cities near Raleigh, NC are hiring for Utilization Management jobs? Cities near Raleigh, NC with the most Utilization Management job openings:
Infographic showing various Utilization Management job openings in Raleigh, NC as of June 2026, with employment types broken down into 83% Full Time, 15% Part Time, and 2% Contract. Highlights an 92% Physical, 2% Hybrid, and 6% Remote job distribution, with an average salary of $86,979 per year, or $41.8 per hour.
Payer Utilization Management & Business Integration, Senior Associate

Payer Utilization Management & Business Integration, Senior Associate

Pwc

Raleigh, NC

$77K - $202K/yr

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 2 days ago


PwC rating

8.3

Company rating: 8.3 out of 10

Based on 73 frontline employees who took The Breakroom Quiz

20th of 57 rated business consultants


Job description

Industry/Sector

Health Services

Specialism

Operations

Management Level

Senior Associate

Job Description & Summary

At PwC, our people in operations consulting specialise in providing consulting services on optimising operational efficiency and effectiveness. These individuals analyse client needs, develop operational strategies, and offer guidance and support to help clients streamline processes, improve productivity, and drive business performance.
As an operations consulting generalist at PwC, you will possess a broad understanding of various aspects of operations consulting. You will provide comprehensive guidance and support to clients in optimising operational efficiency and effectiveness. Working in this area, you will analyse client needs, develop operational solutions, and offer recommendations tailored to specific business requirements.
Focused on relationships, you are building meaningful client connections, and learning how to manage and inspire others. Navigating increasingly complex situations, you are growing your personal brand, deepening technical expertise and awareness of your strengths. You are expected to anticipate the needs of your teams and clients, and to deliver quality. Embracing increased ambiguity, you are comfortable when the path forward isn't clear, you ask questions, and you use these moments as opportunities to grow.
Examples of the skills, knowledge, and experiences you need to lead and deliver value at this level include but are not limited to:
Respond effectively to the diverse perspectives, needs, and feelings of others.
Use a broad range of tools, methodologies and techniques to generate new ideas and solve problems.
Use critical thinking to break down complex concepts.
Understand the broader objectives of your project or role and how your work fits into the overall strategy.
Develop a deeper understanding of the business context and how it is changing.
Use reflection to develop self awareness, enhance strengths and address development areas.
Interpret data to inform insights and recommendations.
Uphold and reinforce professional and technical standards (e.g. refer to specific PwC tax and audit guidance), the Firm's code of conduct, and independence requirements.
The Opportunity
As part of the Operations Consulting team, you will manage day-to-day delivery of technology implementation and systems integration initiatives, serving as the bridge between strategy, architecture, and execution. As a Senior Associate, you will analyze complex problems, mentor others, and maintain significant standards while building meaningful client connections and navigating increasingly complex situations. This role offers the chance to enhance your personal brand and technical knowledge while aligning implementation outcomes with business objectives.
Responsibilities
- Oversee daily operations of technology implementation and systems integration projects
- Serve as a liaison between strategic planning and execution phases
- Analyze intricate issues and provide actionable insights
- Mentor junior team members and foster their professional growth
- Maintain quality standards throughout project delivery
- Build and maintain relationships with clients
- Navigate complex challenges to achieve successful outcomes
- Enhance personal brand and technical skills through continuous learning
What You Must Have
- Bachelor's Degree
- At least 4 years of experience
What Sets You Apart
- Master's Degree preferred
- Hands-on experience redesigning UM workflows
- Connecting operational processes to reporting and analytics needs
- Translating business needs into clear BI requirements
- Demonstrating facilitation skills in working sessions
- Owning workstream delivery and team outcomes
- Managing junior team members and delivery activities
- Developing client-ready deliverables and executive presentations

Travel Requirements

Up to 80%

Job Posting End Date

The salary range for this position is: $77,000 - $202,000. Actual compensation within the range will be dependent upon the individual's skills, experience, qualifications and location, and applicable employment laws. All hired individuals are eligible for an annual discretionary bonus. PwC offers a wide range of benefits, including medical, dental, vision, 401k, holiday pay, vacation, personal and family sick leave, and more. To view our benefits at a glance, please visit the following link: https://pwc.to/benefits-at-a-glanceAs PwC is anequal opportunity employer, all qualified applicants will receive consideration for employment at PwC without regard to race; color; religion; national origin; sex (including pregnancy, sexual orientation, and gender identity); age; disability; genetic information (including family medical history); veteran, marital, or citizenship status; or, any other status protected by law.PwC does not intend to hire experienced or entry level job seekers who will need, now or in the future, PwC sponsorship through the H-1B lottery, except as set forth within the following policy: https://pwc.to/H-1B-Lottery-Policy.Learn more about how we work: https://pwc.to/how-we-workFor only those qualified applicants that are impacted by the Los Angeles County Fair Chance Ordinance for Employers, the Los Angeles' Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, San Diego County Fair Chance Ordinance, and the California Fair Chance Act, where applicable, arrest or conviction records will be considered for Employment in accordance with these laws. At PwC, we recognize that conviction records may have a direct, adverse, and negative relationship to responsibilities such as accessing sensitive company or customer information, handling proprietary assets, or collaborating closely with team members. We evaluate these factors thoughtfully to establish a secure and trusted workplace for all.Applications will be accepted until the position is filled or the posting is removed, unless otherwise set forth on the following webpage. Please visit this link for information about anticipated application deadlines: https://pwc.to/us-application-deadlines

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