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Utilization Review Nurse Jobs in Raleigh, NC (NOW HIRING)

Duke University

Utilization Manager

Durham, NC · On-site

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Reviews records for medical necessity and collaborates with physician (s) and members of the care ...

Duke Health

Utilization Manager

Durham, NC

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Reviews records for medical necessity and collaborates with physician (s) and members of the care ...

Duke Health

Utilization Manager

Durham, NC · On-site

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Reviews records for medical necessity and collaborates with physician (s) and members of the care ...

Duke University

Utilization Manager

Durham, NC

Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 ... Reviews records for medical necessity and collaborates with physician (s) and members of the care ...

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All JobsUtilization Review Nurse JobsUtilization Review Nurse Jobs in Raleigh, NC

Utilization Review Nurse information

See Raleigh, NC salary details

$20

$41

$67

How much do utilization review nurse jobs pay per hour?

As of Aug 1, 2026, the average hourly pay for utilization review nurse in Raleigh, NC is $41.10, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.21 per hour, depending on experience, location, and employer.

How to make $300,000 as a nurse?

To earn $300,000 as a Utilization Review Nurse, professionals typically need extensive experience, advanced certifications such as CCM or ANCC, and may work in high-paying healthcare settings or take on additional responsibilities like case management or leadership roles. Working overtime, specializing in complex cases, or pursuing advanced degrees can also increase earning potential.

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

To thrive as a Utilization Review Nurse, you need a strong background in clinical nursing, critical thinking, and knowledge of healthcare regulations, usually supported by an RN license and nursing degree. Familiarity with utilization management software, medical coding systems (like ICD-10 and CPT), and case management certifications (such as CCM or URAC) is typically required. Excellent communication, negotiation, and organizational skills help you collaborate with providers and advocate for patient care while managing complex cases. These skills ensure appropriate resource use, regulatory compliance, and high-quality patient outcomes in healthcare settings.

What does a Utilization Review Nurse do?

A Utilization Review Nurse is responsible for evaluating the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, coordinate with healthcare providers, and ensure that care meets established guidelines and insurance requirements. Their primary goal is to ensure patients receive appropriate care while helping to manage healthcare costs and prevent unnecessary procedures.

What are some typical challenges Utilization Review Nurses face when communicating with healthcare providers and insurance companies?

Utilization Review Nurses often need to balance clinical judgment with insurance guidelines, which can lead to challenging conversations with providers who may disagree with coverage decisions. They must clearly explain the rationale behind approvals or denials and ensure all documentation is thorough and compliant. Navigating differing priorities while maintaining positive, professional relationships is key, and strong communication skills help facilitate collaboration and resolve conflicts efficiently.

What Does a Utilization Review Nurse Do?

A utilization review nurse determines the best course of treatment for a patient using preapproved policy criteria. Utilization review nurses collect and review patient records, clinical documentation, and billing information to recommend the best use of patient care resources. Their assessments help determine the length of hospital stays, the effectiveness of the care plan, and the necessity of the services administered. Utilization review nurses inform and educate patients about their options based on their insurance benefits and limitations. Utilization review nurses also assess patient care services in clinical appeals for approval or denial.

What does a nurse do in a utilization review?

A utilization review nurse evaluates medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They ensure that patient care aligns with insurance policies and clinical guidelines, often working with healthcare providers and insurance companies to approve or deny services. This role requires strong clinical knowledge, attention to detail, and familiarity with healthcare regulations and documentation tools.

How to get into utilization review as a nurse?

To become a utilization review nurse, candidates typically need a registered nurse (RN) license and experience in clinical settings. Additional certifications such as Certified Professional in Healthcare Quality (CPHQ) or case management credentials can improve job prospects, and familiarity with medical records, insurance policies, and utilization review software is often required.

What is the difference between Utilization Review Nurse vs Case Manager?

AspectUtilization Review NurseCase Manager
CredentialsRN license, certification in utilization review (e.g., URAC)RN license, case management certification (e.g., CCM)
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, insurance companies, community health settings
Employer & Industry UsagePrimarily in insurance and healthcare organizations for reviewing medical necessityIn healthcare and insurance for coordinating patient care and discharge planning

Utilization Review Nurses focus on evaluating the necessity and appropriateness of medical services, often working in insurance or healthcare settings. Case Managers coordinate patient care, discharge planning, and resource management. While both roles require RN licensure and related certifications, their primary responsibilities differ: UR Nurses review medical necessity, whereas Case Managers facilitate patient care and services.

Is it hard to be a utilization review nurse?

Being a utilization review nurse involves reviewing medical records and determining appropriate care levels, which requires strong clinical knowledge, attention to detail, and good communication skills. The job can be demanding due to tight deadlines, the need for accuracy, and the responsibility of making critical decisions that impact patient care and insurance processes.
More about Utilization Review Nurse jobs
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What cities near Raleigh, NC are hiring for Utilization Review Nurse jobs? Cities near Raleigh, NC with the most Utilization Review Nurse job openings:
Utilization Review Nurse jobs near you
Infographic showing various Utilization Review Nurse job openings in Raleigh, NC as of July 2026, with employment types broken down into 3% As Needed, 61% Full Time, 15% Part Time, and 21% Contract. Highlights an 98% Physical, and 2% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

Utilization Review Nurse

Granville Health System

Oxford, NC

Other

Re-posted 11 days ago

Granville Health System rating

8.6

Company rating: 8.6 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Job description

Position Summary:

Conducts patient reviews as specified in review plan using screening criteria; identifies and documents actual and potential delays in services or treatment and works with departments and other providers to resolve problems; communicates to attending physician need for documentation for admission or continuation of hospitalization; refers cases that do not meet criteria to Director when needed. Screens all cases against high risk screens for discharge planning; conduct concurrent and retrospective reviews.

Qualifications:

North Carolina License as a Registered Nurse. Three years clinical nursing experience. One year utilization and review experience. Experience with MCG authorization criteria preferred. Knowledge of current nursing principles, techniques, procedures; knowledge of current utilization management criteria and standards. Excellent communication skills. Ability to work with physicians and hospital staff. Maintains professional knowledge and skills related to areas of responsibility. Self direction with the ability to work with minimal supervision and manage multiple tasks. Demonstrates understanding of variations in care of the following age groups - newborn, infant, child, adolescent, adult and geriatric.

What Granville Health System employees say

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Hours and flexibility

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