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Utilization Review Physician Jobs in Raleigh, NC

Duke Health

Utilization Manager

Durham, NC

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke Health

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke University

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

Duke University

Utilization Manager

Durham, NC · On-site

Reviews records for medical necessity and collaborates with physician (s) and members of the care ... Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM ...

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

Utilization Review Physician information

See Raleigh, NC salary details

$20

$41

$67

How much do utilization review physician jobs pay per hour?

As of Sep 5, 2026, the average hourly pay for utilization review physician 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.

What is a utilization review physician?

A Utilization Review Physician is a medical doctor who evaluates the necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities. They review patient medical records, treatment plans, and insurance policies to ensure that the care provided meets established guidelines and is medically necessary. Their work helps healthcare organizations and insurance companies manage costs while ensuring patients receive proper care. Utilization Review Physicians often collaborate with healthcare providers and insurance representatives to make coverage and care decisions. They play a critical role in maintaining quality standards in healthcare delivery.

What does a utilization review physician do?

A utilization review physician depresses healthcare costs and prevents medical resource overuse. You typically work with health insurance companies to review claims or pre-authorization requests submitted by other doctors. Your other responsibilities include informing doctors of the reasons for coverage refusal, whether it be for treatment, medication, or another request. You write medical review reports, ensure requests fit the patient’s coverage or insurance plan, ensure medical necessity for hospitalization incidents, perform pharmaceutical reviews, schedule independent medical examinations, and make sure that prescribed drugs are truly necessary. You may also work for a disability insurance company to determine the qualifications regarding payouts.

How does a utilization review physician typically interact with other healthcare professionals during the review process?

Utilization Review Physicians regularly collaborate with case managers, nurses, attending physicians, and insurance representatives to assess the medical necessity and appropriateness of patient care. They review clinical documentation, provide feedback, and may request additional information to ensure that care meets established guidelines. Clear communication and a collaborative approach are essential, as the role often involves discussing complex cases and educating clinical staff on best practices and compliance requirements.

What are the key skills and qualifications needed to thrive as a utilization review physician, and why are they important?

To thrive as a Utilization Review Physician, you need a medical degree (MD or DO), board certification in a clinical specialty, and in-depth knowledge of evidence-based medicine and healthcare regulations. Familiarity with utilization management software, electronic health records (EHRs), and compliance standards such as CMS guidelines is crucial. Strong analytical skills, attention to detail, and effective communication are essential soft skills for reviewing cases and collaborating with healthcare teams. These competencies ensure accurate assessments, cost-effective care, and adherence to regulatory requirements in the healthcare system.

What is the difference between Utilization Review Physician vs Medical Director?

AspectUtilization Review PhysicianMedical Director
CredentialsMedical degree, medical license, board certification in relevant specialtyMedical degree, medical license, often additional leadership or management certifications
Work EnvironmentHospitals, insurance companies, healthcare organizations, primarily review and evaluate patient casesHealthcare organizations, insurance companies, overseeing clinical operations and policy development
Employer & Industry UsageUsed in insurance, managed care, and healthcare facilities for utilization reviewUsed in healthcare organizations and insurance companies for leadership and policy oversight

The Utilization Review Physician focuses on evaluating patient cases to determine appropriate care and resource use, while the Medical Director oversees clinical policies and manages healthcare operations. Both roles require medical credentials, but the Medical Director often has additional leadership responsibilities.

Is utilization review a good job?

Utilization review physicians evaluate medical necessity and appropriateness of healthcare services, often working in insurance companies or healthcare organizations. The role typically requires strong clinical knowledge, attention to detail, and familiarity with medical guidelines, with schedules that can be regular or flexible depending on the employer. It can offer a stable career with opportunities for advancement and work-life balance, but job satisfaction depends on individual preferences and work environment.
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Cities near Raleigh, NC with the most Utilization Review Physician job openings:

Utilization Review Physician jobs near you
Infographic showing various Utilization Review Physician job openings in Raleigh, NC as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 12% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 2% Hybrid, and 11% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

Utilization Review Specialist

Memorial Physician Practices

Raleigh, NC • On-site

$60 - $85/hr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Posted 4 days ago

Key responsibilities

  • Facilitates clinical reviews on all patient admissions and continued stays to determine the legitimacy of admission, treatment, and length of stay.

  • Interfaces with managed care organizations, external reviewers, and other payers to obtain authorization, certification, and communicate insurance requirements.

  • Completes pre- and re-certifications for inpatient and outpatient services, ensuring documentation and appeals are handled thoroughly and timely.

Job description

Your experience matters

Lifepoint Behavioral Health is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. Triangle Springs is a 77-bed behavioral health hospital located in Raleigh, North Carolina, providing care for patients with mental health and substance use disorders. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Registered Nurse (RN) joining our team, you're embracing a vital mission dedicated to making communities healthier®. Join us on this meaningful journey where your skills, compassion, and dedication will make a remarkable difference in the lives of those we serve.

How you'll contribute

Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine legitimacy of admission, treatment, and length of stay and interfaces with managed care organizations, external reviewers and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to manage care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning.

Job Responsibilities
  • Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed services
  • Complete pre and re-certifications for inpatient and outpatient services. Reports appropriate denial, and authorization information to designated resource.
  • Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
  • Participate in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
  • Works with DON to ensure documentation requirements are met.
  • Ensure appeals are completed thoroughly and on a timely basis.
  • Interface with managed care organizations, external reviews, and other payers.
  • Communicate with physicians to schedule peer-to-peer reviews.
What we're looking for
  • Education: Bachelor's degree required. Master's degree preferred.
  • Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
  • License: Current unencumbered clinical license strongly preferred.
  • Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred.
Why join us

We believe that investing in our employees is the first step to providing excellent patient care. In addition to your base compensation, this position also offers:

  • Comprehensive Benefits: Multiple levels of medical, dental, and vision coverage for full-time and part-time employees
  • Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave, and paid time off
  • Financial & Career Growth: Tuition reimbursement and 401(k) retirement package with company match
  • Employee Well-being: Mental, physical, and financial wellness programs, including Employee Assistance Program and discount programs
  • Professional Development: Ongoing learning and career advancement opportunities
  • Additional Perks: Shift differentials and set schedules
EEOC Statement

Lifepoint Behavioral Health is an Equal Opportunity Employer. Lifepoint Behavioral Health is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.

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