Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization)
Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization)
Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization)
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Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization)
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 ...
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 ...
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 ...
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 ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Case management needs including care coordination/transition and discharge planning, consultations ...
Drug Utilization Review Pharmacist
Raleigh, NC · On-site +1
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
Drug Utilization Review Pharmacist
Raleigh, NC · On-site +1
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
Authorization Specialist
Raleigh, NC · On-site
$17.50 - $23.25/hr
Communicate professionally with payor representatives and utilization management teams. * Support advocacy efforts aligned with clinical recommendations and organizational standards Process Support ...
Authorization Specialist
Raleigh, NC · On-site
$17.50 - $23.25/hr
Communicate professionally with payor representatives and utilization management teams. * Support advocacy efforts aligned with clinical recommendations and organizational standards Process Support ...
Care Coordinator, RN
Cary, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third-party utilization management regulatory requirements.
Care Coordinator, RN
Cary, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third-party utilization management regulatory requirements.
Care Coordinator, RN
Raleigh, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third party utilization management regulatory requirements.
Care Coordinator, RN
Raleigh, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third party utilization management regulatory requirements.
Care Coordinator, RN
Raleigh, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third party utilization management regulatory requirements.
Care Coordinator, RN
Raleigh, NC · On-site
The Care Coordinator will also act as an advocate for the patient, physician and hospital relative to compliance with federal, state and third party utilization management regulatory requirements.
The Analyst will create and manage reports that monitor care utilization, premium, and MLR. The Analyst will support the Director of Medical Economics in identifying potential cost of care ...
The Analyst will create and manage reports that monitor care utilization, premium, and MLR. The Analyst will support the Director of Medical Economics in identifying potential cost of care ...
Field Medical Director, Radiation Oncology As a FMD, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non ...
Field Medical Director, Radiation Oncology As a FMD, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non ...
Physician Reviewer-Radiology (Part Time)
$95 - $100/hr
As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy ...
Physician Reviewer-Radiology (Part Time)
$95 - $100/hr
As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy ...
RN Care Manager - (Per Diem) Care Management
Smithfield, NC · On-site
$35.87 - $51.57/hr
As necessary meet with the Utilization Manager (UM) and SW after the meeting to discuss updates and action items. 3. Complex Care Meeting - Attend weekly Complex Care Meeting (CCM). Present on ...
RN Care Manager - (Per Diem) Care Management
Smithfield, NC · On-site
$35.87 - $51.57/hr
As necessary meet with the Utilization Manager (UM) and SW after the meeting to discuss updates and action items. 3. Complex Care Meeting - Attend weekly Complex Care Meeting (CCM). Present on ...
Currently seeking Endocrinologist Physicians to join our Radiology department As an FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to ...
Currently seeking Endocrinologist Physicians to join our Radiology department As an FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to ...
Utilization Management information
See Raleigh, NC salary details
$37.9K - $48.9K
15% of jobs
$48.9K - $59.8K
8% of jobs
$61.4K is the 25th percentile. Wages below this are outliers.
$59.8K - $70.8K
15% of jobs
The median wage is $77.7K / yr.
$70.8K - $81.7K
20% of jobs
$81.7K - $92.7K
11% of jobs
$98.2K is the 75th percentile. Wages above this are outliers.
$92.7K - $103.7K
13% of jobs
$103.7K - $114.6K
5% of jobs
$114.6K - $125.6K
3% of jobs
$125.6K - $136.5K
4% of jobs
$136.5K - $147.5K
3% of jobs
$147.5K - $158.4K
3% of jobs
$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 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:
- Remote Utilization Management
- Night Utilization Review Nurse
- Utilization Management Nurse Consultant
- Cvs Health Utilization Management
- Utilization Review Physician
- Overnight Utilization Review Nurse
- Evening Optum Health Utilization Review
- Manager Utilization Management
- Utilization Management Physician Reviewer
- No Experience Utilization Management Nurse
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:
- Remote Utilization Review
- Nurse Practitioner Utilization Review
- Remote Occupational Therapy Utilization Review
- Remote Bcba Utilization Review
- Remote Aetna Utilization Review
- Director Remote Utilization Review
- Remote Aetna Utilization Review Nurse
- Chart Utilization Review
- Temporary Medical Utilization Review Physician
- Registered Nurse Case Review
What cities near Raleigh, NC are hiring for Utilization Management jobs? Cities near Raleigh, NC with the most Utilization Management job openings:
Senior Data Analyst, Clinical Programs
Brighton Health Plan Solutions, LLCChapel Hill, NC • On-site, Remote
Full-time
Medical, Vision
Posted 18 days ago
Job description
About The Role
The Senior Data Analyst, Clinical Programs will be an analytically driven team player, responsible for understanding business needs and objectives, eliciting requirements from stakeholders, and analyzing data and processes to identify opportunities for improvement. This role will support BHPS Clinical Programs, Utilization Management, Complex Case Management, and Population Health Management. In this role, you will be challenged to think creatively while developing actionable insights to inform client and program strategy.
Primary Responsibilities
About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you'll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you'll be encouraged to bring your authentic self to work with all of your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today's healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today's challenges into tomorrow's solutions.
Come be a part of the Brightest Ideas in Healthcare™.
Company Mission
Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners.
Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected]
The Senior Data Analyst, Clinical Programs will be an analytically driven team player, responsible for understanding business needs and objectives, eliciting requirements from stakeholders, and analyzing data and processes to identify opportunities for improvement. This role will support BHPS Clinical Programs, Utilization Management, Complex Case Management, and Population Health Management. In this role, you will be challenged to think creatively while developing actionable insights to inform client and program strategy.
Primary Responsibilities
- Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization)
- Develop statistical models that deliver meaningful insights on cost, utilization and clinical outcomes based on various data sources.
- Develop algorithms for stratifying populations and identifying high-risk members.
- Leverage Predictive Analytics to measure the performance (ROI) of Disease Management and other Medical Management programs.
- Conduct prospective savings analyses in support of clinical program initiatives.
- Build and maintain client-facing reports, dashboards, and analyses.
- Develop actionable data insights and advise on client strategy
- Participate in program performance review presentations with clinical program managers, client account managers, and external clients, as needed.
- Manage internal and external client requests and timelines to ensure timely delivery.
- Collaborate with Medical Management to provide ongoing support.
- Bachelors' degree required, preferably in Mathematics, Statistics, Finance, Actuarial Science, Data Science, or related field.
- 5-7 years of experience in healthcare analytics, preferably in a managed care setting.
- Proficiency in SQL and Microsoft SQL Server Suite of Products (SSMS) required.
- Proficiency in MS Excel required.
- Advanced data analysis, financial modeling, and predictive analytics skills.
- Experience with clinical program evaluation and outcomes reporting.
- Experience with health plan performance reporting and cost and utilization analysis.
- Experience with developing client-facing reports.
- Experience with Business Intelligence applications and DAX functions (PowerPivot, Power BI, Tableau).
- Ability to explain technical concepts to a non-technical audience .
- Ability to effectively manage and prioritize several concurrent projects.
- Excellent oral and written communications skills.
- Experience with Payer Care Management platforms (i.e. ZeOmega) a plus.
About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you'll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you'll be encouraged to bring your authentic self to work with all of your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today's healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today's challenges into tomorrow's solutions.
Come be a part of the Brightest Ideas in Healthcare™.
Company Mission
Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners.
Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected]
About Brighton Health Plan Solutions
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