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Utilization Manager Jobs in Raleigh, NC (NOW HIRING)

Duke Health

Behavioral Health Case Manager

Durham, NC · On-site

Ensure optimum utilization of the patient's and the Health System's resources and perform these ... Work with Utilization Management partners to provide information and feedback that will enhance ...

Cynet Health

RN - Case Manager

Chapel Hill, NC

This position promotes continuity of care and cost-effectiveness through the integration of case management, utilization review, and discharge planning. The Care Manager must be a highly organized ...

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Utilization Manager information

See Raleigh, NC salary details

$37.9K

$88.5K

$162.8K

How much do utilization manager jobs pay per year?

As of May 30, 2026, the average yearly pay for utilization manager in Raleigh, NC is $88,465.00, according to ZipRecruiter salary data. Most workers in this role earn between $57,800.00 and $106,400.00 per year, depending on experience, location, and employer.

What Is a Utilization Manager?

A utilization manager works in the insurance industry to analyze health care needs in medical cases and determine further patient care. In this career, your job duties include conducting interviews to determine what services you register for and cutting down on unnecessary costs. You may review medical records and compile documentation to improve care and report your findings. Skills in management, customer service, and health care services are vital in this career. Job experience in nursing is a benefit when applying for utilization manager positions. Additional qualifications include a bachelor’s degree and medical case management certificate.

What are the key skills and qualifications needed to thrive as a Utilization Manager, and why are they important?

To thrive as a Utilization Manager, you need a solid background in healthcare management, case review, and knowledge of insurance regulations, often supported by a degree in nursing, healthcare administration, or a related field. Familiarity with utilization management software, electronic health records (EHRs), and certification such as Certified Case Manager (CCM) are typically required. Strong analytical thinking, communication, and negotiation skills help Utilization Managers effectively coordinate care and collaborate with providers. These skills ensure appropriate resource use, regulatory compliance, and optimal patient outcomes within healthcare organizations.

What are some common challenges faced by Utilization Managers, and how can they be addressed?

Utilization Managers often face challenges such as balancing cost containment with patient care quality, navigating complex insurance policies, and managing high caseloads. To address these, effective communication with healthcare providers and payers is essential, as is staying current with regulatory requirements and best practices. Building strong relationships within interdisciplinary teams and leveraging data analytics tools can also help Utilization Managers make informed decisions and improve workflow efficiency.

What does a Utilization Manager do?

A Utilization Manager is responsible for evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their primary goal is to ensure that patients receive the right care at the right time while also controlling costs for hospitals, insurance companies, or healthcare organizations. Utilization Managers review patient records, coordinate with healthcare providers, and use clinical guidelines to make informed decisions about treatment approvals or denials. They play a key role in maintaining quality care and regulatory compliance.

What is the difference between Utilization Manager vs Utilization Coordinator?

AspectUtilization ManagerUtilization Coordinator
CertificationsOften requires healthcare or case management certificationsMay have similar certifications but less emphasis on management
Work EnvironmentTypically in healthcare organizations, overseeing utilization review processesSupports daily operations, assisting with case documentation and scheduling
Employer & Industry UsageCommon in healthcare, insurance, and managed care companiesFound in similar settings, often working under Utilization Managers

In summary, a Utilization Manager generally has broader responsibilities, overseeing utilization review and resource allocation, while a Utilization Coordinator focuses on supporting daily tasks and documentation. Both roles are integral in healthcare settings but differ in scope and level of responsibility.

More about Utilization Manager jobs
What are the most commonly searched types of Utilization jobs in Raleigh, NC? The most popular types of Utilization jobs in Raleigh, NC are:
What are popular job titles related to Utilization Manager jobs in Raleigh, NC? For Utilization Manager jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Utilization Manager jobs in Raleigh, NC look for? The top searched job categories for Utilization Manager jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Utilization Manager jobs? Cities near Raleigh, NC with the most Utilization Manager job openings:
Utilization Manager jobs near you
Infographic showing various Utilization Manager job openings in Raleigh, NC as of May 2026, with employment types broken down into 76% Full Time, 20% Part Time, 1% Temporary, and 3% Contract. Highlights an 98% Physical, and 2% Hybrid job distribution, with an average salary of $88,465 per year, or $42.5 per hour.
Clinical Appeal Nurse

Clinical Appeal Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • On-site

Full-time

Medical, Vision

Posted 8 days ago

Job description

About the Role
BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager.
Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role.
Primary Responsibilities
  • Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances.
  • Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment
  • Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions
  • Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure.
  • Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements
  • Accurately enter case details in medical management platform
  • Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement
Essential Qualifications
  • Active and unrestricted RN or LPN license; must maintain licensure throughout employment
  • Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting
  • Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care)
  • Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA
  • Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application
  • Excellent written and verbal communication skills
  • Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
  • Ability to work independently with exceptional accountability
  • Adaptability to a fast-paced and evolving environment.
  • Preferred experience in a Third-Party Administrator (TPA) setting
  • Preferred coding certification

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: recruiting@brightonhps.com

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