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Utilization Review Rn Jobs in North Carolina (NOW HIRING)

Sagility

RN Utilization Management Reviewer

Concord, NC · Remote

$35 - $40/hr

Job title: RN Utilization Management Reviewer We are currently hiring a talented RN, Utilization ... Conducts timely clinical decision review for services requiring prior authorization in a variety of ...

Integrated Resources

RN-Care Manager

Chapel Hill, NC · On-site

RN - Care Manager | Chapel Hill, NC Location: Chapel Hill, NC Duration: 3+ Months Shift: Days | 8 ... Conduct utilization review and case management activities. * Participate in daily Care Management ...

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Utilization Review Rn information

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How much do utilization review rn jobs pay per hour?

As of Aug 10, 2026, the average hourly pay for utilization review rn in North Carolina is $38.43, according to ZipRecruiter salary data. Most workers in this role earn between $30.38 and $44.13 per hour, depending on experience, location, and employer.

How does a utilization review RN collaborate with physicians and other healthcare professionals during the patient care review process?

A Utilization Review RN works closely with physicians, case managers, and other healthcare team members to ensure that patients receive appropriate care while adhering to regulatory and insurance guidelines. This collaboration often involves discussing clinical findings, clarifying documentation, and negotiating care plans to meet both patient needs and payer requirements. Effective communication and teamwork are essential, as Utilization Review RNs frequently serve as liaisons between clinical staff and insurance representatives to facilitate timely authorizations and prevent unnecessary delays in patient care.

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

To thrive as a Utilization Review RN, you need a current RN license, strong clinical assessment skills, and knowledge of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or ACM is often required. Excellent critical thinking, communication, and negotiation skills help you advocate for appropriate patient care while collaborating with providers and payers. These skills ensure cost-effective, quality care and compliance with regulatory standards in healthcare delivery.

How to get into utilization review as a registered nurse?

To become a utilization review RN, you typically need a valid registered nurse license and experience in clinical settings. Additional certifications such as the Certified Professional in Healthcare Quality (CPHQ) or knowledge of medical coding and insurance processes can enhance your qualifications. Gaining experience in case management or health insurance companies can also improve your chances of entering the field.

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

AspectUtilization Review RnCase Manager
CredentialsRN license, certifications in utilization reviewRN license, certifications in case management
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, community agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of careCoordinating patient care and discharge planning

Utilization Review Rns primarily focus on evaluating the necessity of medical treatments, while Case Managers coordinate patient care and discharge planning. Both roles require RN licensure and certifications, but their daily responsibilities and work environments differ slightly, with Utilization Review Rns concentrating on review processes and Case Managers on patient advocacy and care coordination.

What is a utilization review RN?

A Utilization Review RN is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, collaborate with healthcare teams, and ensure that patient care meets established guidelines and payer requirements. Their role helps control costs, optimize care, and support compliance with healthcare regulations. Utilization Review RNs often work in hospitals, insurance companies, or managed care organizations.
What are the most commonly searched types of Utilization Review Rn jobs in North Carolina? The most popular types of Utilization Review Rn jobs in North Carolina are:
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What job categories do people searching Utilization Review Rn jobs in North Carolina look for? The top searched job categories for Utilization Review Rn jobs in North Carolina are:
What cities in North Carolina are hiring for Utilization Review Rn jobs? Cities in North Carolina with the most Utilization Review Rn job openings:
What are popular job titles related to Utilization Review Rn jobs in NC? For Utilization Review Rn jobs in NC, the most frequently searched job titles are:
Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in North Carolina as of August 2026, with employment types broken down into 10% As Needed, and 90% Full Time. Highlights an 100% In-person job distribution, with an average salary of $79,926 per year, or $38.4 per hour.

RN Utilization Management Reviewer

Sagility

Concord, NC • Remote

$35 - $40/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 2 days ago

Sagility rating

4.6

Company rating: 4.6 out of 10

Based on 29 frontline employees who took The Breakroom Quiz

61st of 71 rated call and contact centers

Job description

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

Job title:

RN Utilization Management Reviewer

Job Description:

We are currently hiring a talented RN, Utilization Management Reviewer. This role will be responsible in day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must hold a valid, current license issued by the Massachusetts Board of Registration in Nursing.

Key responsibilities:

  • Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH)
  • Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
  • Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements
  • Provides decision-making guidance to clinical teams on service planning as needed
  • Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
  • Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy
  • Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met
  • Additional duties as requested by supervisor
  • Maintains knowledge of CMS, State and NCQA regulatory requirements

Education Requirements:

  • RN - Associate's Degree required, Bachelor's Degree preferred
  • RN, current license issued by the Massachusetts Board of Registration in Nursing
  • CCM (Certified Case Manager) a plus

Required Experience (must have):

  • 1 to 2 years Utilization Management experience.
  • 2 or more years working in a clinical setting

Desired Experience (nice to have):

  • 2 or more years of Home Health Care experience
  • 2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

  • Ability to complete assigned work in a timely and accurate manner
  • Knowledge of the Utilization management process
  • Ability to work independently

Desired Knowledge, Skills, Abilities & Language (nice to have):

  • Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity
  • Flexibility and understanding of individualized care plans
  • Ability to influence decision making
  • Strong collaboration and negotiation skills
  • Strong interpersonal, verbal, and written communication skills
  • Comfort working in a team-based environment
  • Knowledge of Medicare and Mass health services and benefits

Salary: $35.00 - $40.00 Hourly pending experience

Hours: Monday through Friday 9AM to 5:30PM Eastern Time. May require weekends

This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.

Sagility Offers Competitive Benefits Including:

  • Medical
  • Dental
  • Vision
  • Life Insurance
  • Short-Term and Long-Term Disability
  • Flexible Spending Account
  • Life Assistance Program
  • 401K with employer contribution
  • PTO and Sick Time
  • Tuition Reimbursement

Join our team, we look forward to talking with you!

An Equal Opportunity Employer/Vet/Disability

Location:

Work@Home USAUnited States of America

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