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Utilization Review Physician Jobs in Raleigh, NC

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 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 ...

Evolent

Physician Reviewer-Radiology (Part Time)

Raleigh, NC · On-site

$95 - $100/hr

  • Medical

Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable ... Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ...

Elevance Health

Prior Authorization Clinical Pharmacist

Durham, NC · On-site

$114K - $136K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

This role supports key clinical pharmacy programs, including Drug Utilization Review (DUR), Drug ... Prepares information for network physicians. * Prepares and presents therapeutic class reviews and ...

Omega Solutions Inc

Pharmacist

Raleigh, NC · On-site

... Utilization Review (DUR) and pharmacy lock-in related processes, Behavioral health, and A+ kids, Preferred Drug List (PDL) and Medicaid Drug Rebate Program (MDRP), and Physicians Administered Drug ...

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How much do utilization review physician jobs pay per hour?

As of Aug 16, 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.

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.

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.
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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, 80% Full Time, 16% Part Time, and 3% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% 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

Per diem

Re-posted 26 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.

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