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Utilization Management Jobs in Raleigh, NC (NOW HIRING)

Pharmacy Careers

Formulary Management Pharmacist

Raleigh, NC · On-site

$56.50 - $68/hr

Provide clinical support for utilization management, prior-authorization criteria, and step-therapy guidelines. What You'll Bring * Education: PharmD or Bachelor of Pharmacy. * Licensure: Active U.S ...

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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 Sep 3, 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 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 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 degree is needed for utilization management?

Utilization management professionals typically need at least a bachelor's degree in healthcare, nursing, health administration, or a related field. Some roles may require a master's degree or professional certifications such as Certified Professional in Healthcare Quality (CPHQ) or Certified Case Manager (CCM). Experience in healthcare settings and knowledge of medical terminology and insurance processes are also important.

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 100% Full Time. Highlights an 80% In-person, 4% Hybrid, and 16% Remote job distribution, with an average salary of $86,979 per year, or $41.8 per hour.

RN - Utilization Review & Care Coordination

MLee Medical Employment

New Hill, NC • On-site

Other

This job post has expired 2 days ago. Applications are no longer accepted.

Job description

Overview: Join a dedicated healthcare team as a Registered Nurse specializing in Utilization Review and Coordination of Care. This role involves evaluating patient admissions and ongoing care to ensure medical necessity and appropriate treatment levels, collaborating closely with physicians and advanced practice providers.
Responsibilities: Conduct initial and concurrent utilization reviews for admitted and observation patients, ensuring compliance with regulatory and payer requirements. Partner with interdisciplinary teams to facilitate clinical guidelines and optimize treatment outcomes in a cost-effective manner. Analyze patient records to determine admission appropriateness, treatment plans, and length of stay. Maintain up-to-date knowledge of regulatory changes affecting utilization management and perform reviews accordingly. Manage denials and appeals in collaboration with management and payors, ensuring timely responses.
Education & Certification: Registered Nurse licensure is required. Certification in Case Management (CCM or ACM) is preferred.
Experience: Ideally, candidates will have three to five years of acute care nursing experience, with a background in medical/surgical or ICU settings. Experience in case management and managed care claims or reimbursement is advantageous.
Skills & Requirements: Strong clinical knowledge and understanding of nursing principles, clinical processes, and interventions. Excellent communication, negotiation, and interpersonal skills to effectively interact with diverse populations. Proficiency with computer systems including Microsoft Office and various healthcare software platforms. Ability to prioritize multiple tasks, demonstrate sound judgment, and work collaboratively with healthcare professionals at all levels. Flexibility and adaptability to change, with a positive approach to team building and respect.
Physical Demands: Some light lifting and walking may be required. The role involves extended periods of sitting and data entry.
This position serves a regional healthcare network in the Southeastern United States, providing comprehensive care across multiple facilities and specialties.
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About McCall and Lee

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McCall and Lee is a well-known and reputable company, headquartered in Austin, Texas, United States. Operating in the healthcare industry, their primary services center around professional recruiting and executive search. They cater to the needs of various levels of medical practitioners and executive positions for healthcare establishments. McCall and Lee is founded on the premise of filling healthcare vacancies with the most suitable and competent professionals to ensure top-quality medical service delivery. Their core value revolves around integrity, excellence, commitment, and customer satisfaction.

Industry

Recruiting and staffing services and human resources consulting services

Company size

11 - 50 Employees

Headquarters location

Austin, TX, US

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