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

Duke Health

Utilization Manager 30 hour EOW

Durham, NC · On-site

Duke University Health System has 6000 + registered nurses * Quality of Life: Living in the ... Reviews records for medical necessity and collaborates with physician (s) and members of the care ...

Rose Manor Health and Rehab

MDS Coordinator (RN)

Durham, NC · On-site

$33.75 - $40.75/hr

... utilization review meetings • Ensure timely completion, validation, and transmission of all MDS assessments • Collaborate with therapy, nursing, and interdisciplinary team members on ARDs and ...

Star Nursing, Inc.

Be Seen First

Registered Nurse RN

Butner, NC · On-site

$58/hr

Review admission requests for medical necessity * Ensure proper approvals and pre-certifications ... Support urgent and emergent admissions with utilization teams * Document all patient and transfer ...

Granville Health System

LPN/ RN

Oxford, NC · On-site

$25 - $34/hr

... utilization of the nursing process in collaboration with other health team members. The LPN or RN ... will be responsible for meeting the standards required by JCAHO, GHS, and other regulating agencies ...

Granville Health System

LPN/ RN

Oxford, NC · On-site

$25 - $34/hr

... utilization of the nursing process in collaboration with other health team members. The LPN or RN ... will be responsible for meeting the standards required by JCAHO, GHS, and other regulating agencies ...

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

Utilization Review Rn information

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$20

$41

$67

How much do utilization review rn jobs pay per hour?

As of Jun 14, 2026, the average hourly pay for utilization review rn 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 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.

How do I become a utilization review RN?

To become a utilization review RN, you typically need to hold a valid registered nurse (RN) license and have experience in clinical nursing. Additional certifications such as the Certified Professional in Healthcare Quality (CPHQ) or Utilization Review Certification (URAC) can enhance job prospects, and strong knowledge of medical coding, insurance policies, and healthcare regulations is important.

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.

What does an RN utilization review do?

An RN utilization review evaluates medical records and treatment plans to determine the appropriateness, necessity, and efficiency of healthcare services. They ensure compliance with insurance policies and clinical guidelines, often using electronic health records and requiring knowledge of coding and documentation standards. This role supports cost-effective patient care and involves collaboration with healthcare providers and insurance companies.

How to make $300,000 a year as a nurse?

To earn $300,000 annually as a Utilization Review RN, professionals typically need extensive experience, advanced certifications such as CCM or ANCC, and may work in high-paying settings like insurance companies or healthcare consulting firms. Increasing specialization, taking on leadership roles, or working overtime can also boost income, but reaching this level often requires a combination of skills, experience, and strategic career moves.

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.

How to make $150,000 as a nurse?

A Utilization Review RN can earn $150,000 by gaining extensive experience, obtaining certifications such as CCM or ANCC, and working in high-paying settings like insurance companies or managed care organizations. Advanced skills in case management, strong clinical knowledge, and sometimes working overtime or in leadership roles can also contribute to higher earnings.

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 Raleigh, NC? The most popular types of Utilization Review Rn jobs in Raleigh, NC are:
What are popular job titles related to Utilization Review Rn jobs in Raleigh, NC? For Utilization Review Rn jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Utilization Review Rn jobs in Raleigh, NC look for? The top searched job categories for Utilization Review Rn jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Utilization Review Rn jobs? Cities near Raleigh, NC with the most Utilization Review Rn job openings:
Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Raleigh, NC as of June 2026, with employment types broken down into 85% Full Time, and 15% Part Time. Highlights an 85% In-person, and 15% Remote job distribution, with an average salary of $85,491 per year, or $41.1 per hour.

RN - Utilization Review & Care Coordination

MLee Medical Employment

New Hill, NC

Other

Posted 12 days ago

Job description

Overview: Join a dedicated healthcare team as a Registered Nurse specializing in Utilization Review and Coordination of Care. This role involves evaluating patient admissions and ongoing care to ensure medical necessity and appropriate treatment levels, collaborating closely with physicians and advanced practice providers.
Responsibilities: Conduct initial and concurrent utilization reviews for admitted and observation patients, ensuring compliance with regulatory and payer requirements. Partner with interdisciplinary teams to facilitate clinical guidelines and optimize treatment outcomes in a cost-effective manner. Analyze patient records to determine admission appropriateness, treatment plans, and length of stay. Maintain up-to-date knowledge of regulatory changes affecting utilization management and perform reviews accordingly. Manage denials and appeals in collaboration with management and payors, ensuring timely responses.
Education & Certification: Registered Nurse licensure is required. Certification in Case Management (CCM or ACM) is preferred.
Experience: Ideally, candidates will have three to five years of acute care nursing experience, with a background in medical/surgical or ICU settings. Experience in case management and managed care claims or reimbursement is advantageous.
Skills & Requirements: Strong clinical knowledge and understanding of nursing principles, clinical processes, and interventions. Excellent communication, negotiation, and interpersonal skills to effectively interact with diverse populations. Proficiency with computer systems including Microsoft Office and various healthcare software platforms. Ability to prioritize multiple tasks, demonstrate sound judgment, and work collaboratively with healthcare professionals at all levels. Flexibility and adaptability to change, with a positive approach to team building and respect.
Physical Demands: Some light lifting and walking may be required. The role involves extended periods of sitting and data entry.
This position serves a regional healthcare network in the Southeastern United States, providing comprehensive care across multiple facilities and specialties.

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