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

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 ...

Integrated Resources

RN-Care Manager

Chapel Hill, NC · On-site

Job Title: RN-Care Manager Location: Chapel Hill, NC 27514 Duration: 13 weeks Shift/Schedule: Days ... Perform case management, utilization review, and discharge planning activities. * Review daily ...

New Hope

LEAD REGISTERED NURSE BUTNER NC

Butner, NC · On-site

The Lead RN oversees nursing operations, supervises nursing staff, ensures compliance with nursing ... Participates in quality improvement, utilization review, infection control, and risk management ...

New Hope

LEAD REGISTERED NURSE BUTNER NC

Butner, NC · On-site

The Lead RN oversees nursing operations, supervises nursing staff, ensures compliance with nursing ... Participates in quality improvement, utilization review, infection control, and risk management ...

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Showing results 21-40

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

Utilization Review Rn information

See Raleigh, NC salary details

$20

$41

$67

How much do utilization review rn jobs pay per hour?

As of Aug 23, 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.

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.

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.

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 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 case management certification can enhance job prospects, and familiarity with electronic health records (EHR) systems is often required.

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 August 2026, with employment types broken down into 8% As Needed, 65% Full Time, 8% Part Time, 5% Temporary, and 14% Contract. Highlights an 86% In-person, and 14% Remote job distribution, with an average salary of $85,486 per year, or $41.1 per hour.

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • On-site, Remote

Full-time

Re-posted 17 days ago

Job description

About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member's benefit coverage while working remotely.
Primary Responsibilities
• Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
• Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Collaborates with healthcare partners to ensure timely review of services and care.
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages and prioritizes cases and other assigned duties to meet required turnaround times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
• Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Duties as assigned.
Essential Qualifications
• Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be able to work independently.
• Must be detail oriented and have strong organizational and time management skills.
• Adaptive to a high pace and changing environment- flexibility in assignment.
• Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
• Proficient in MCG and CMS criteria sets
• Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
• Working knowledge of URAC and NCQA.
• 2+ years' experience in a UM team within managed care setting.
• 3+ years' experience in clinical nurse setting preferred.
• TPA Experience preferred.

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