Utilization review nurse jobs in Raleigh, NC - 91 jobs
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SignOn Bonus + One Weekend a Month = Your Perfect Nursing Job!
Southern Health Partners Inc. 3.1
Utilization review nurse job in Louisburg, NC
Now Hiring in Franklin County Jail!
Full-Time RN or LPN - Day Shift $32/hour + SIGN-ON & RETENTION BONUS!
Schedule: 3/4 Day Shift Rotation | 8 a.m. - 8 p.m. Only 1 Weekend per Month - More time for YOU!
Work Today, Get Paid Today with DailyPay - because waiting for payday is so last year.
$32 hourly 1d ago
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Utilization Review & Revenue Cycle Management
Advaita Health
Utilization review nurse job in Raleigh, NC
Job Description
About Us
Advaita Health is committed to a sustainable, integrated model of behavioral healthcare where providers, staff, and patients thrive. Our clinical and operational teams work hand-in-hand, ensuring patients receive the best possible care while critical behind-the-scenes processes, like revenue cycle management, are handled with accuracy and integrity. Every role at Advaita Health contributes to our mission of delivering high-quality, accessible behavioral health services-and our revenue cycle team plays an essential part in supporting both our patients and our financial health.
Our goal for you is simple: to create a place where you can build a lasting career, maintain balance, and perform meaningful work without burning out. We support this through:
Workloads and expectations that protect time for accuracy and growth
Mentorship, training, and leadership development
Performance measures based on values and competencies, not just numbers
Built-in collaboration and transparency across teams
Technology that supports efficiency rather than obstructs it
Why Join Advaita Health?
Full-time, hourly, non-exempt position
Opportunity to work closely with clinical, administrative, and finance teams
401(k) with employer match
3 weeks of PTO and 10 paid federal holidays
Flexible health, dental, and vision coverage; HSA/FSA options
Free life insurance up to $10,000; short- and long-term disability coverage
Employee Assistance Program (EAP) with therapy and financial support
What We're Looking For
We're seeking a UtilizationReview & Revenue Cycle Coordinator who is detail-oriented, organized, and proactive-someone who understands the importance of payer compliance, authorization management, and clean revenue cycle processes in behavioral health and substance use disorder services.
This role has a primary focus on utilizationreview activities, including insurance verification, authorization tracking, and clinical reviews, while also supporting key revenue cycle functions such as claims follow-up and denial resolution. Success in this role requires strong communication skills, the ability to interpret clinical and billing documentation, and a collaborative mindset.
You'll thrive here if you're someone who:
Enjoys working cross-functionally with clinical and administrative teams
Takes ownership of processes and follows through on details
Values accuracy, compliance, and professionalism
Wants to contribute to systems that support both patient care and organizational sustainability
Key Responsibilities
Track and manage authorizations, units, and levels of care in accordance with payer guidelines
Verify insurance benefits and authorization requirements prior to enrollment
Submit authorization requests and clinical reviews using appropriate documentation and criteria (including ASAM, when applicable)
Resolve authorization denials and partial approvals in collaboration with clinical leadership
Support revenue cycle operations, including claims submission, denial follow-up, and reimbursement tracking
Communicate with insurance carriers to resolve authorization and billing discrepancies
Maintain accurate documentation and ensure HIPAA and regulatory compliance
Qualifications
Bachelor's degree in Healthcare Administration, Business, or a related field-or equivalent experience
Working knowledge of utilizationreview and revenue cycle workflows
Experience with insurance verification, authorizations, and claims follow-up
Strong organizational skills and attention to detail
Professional, dependable, and collaborative
Preferred Experience
1-3 years of experience with insurance denials and appeals
Familiarity with ASAM criteria and managed care requirements
Experience in behavioral health and/or substance use disorder billing
Experience with EMR systems (AdvancedMD preferred)
We don't expect long hours, but we do expect professionalism, engagement, and a willingness to learn.
Ready to Join Us?
If you're looking for more than just a job-if you want a career where your expertise supports patients, providers, and the sustainability of behavioral healthcare-we'd love to hear from you.
$44k-69k yearly est. 9d ago
Utilization Management Nurse
Centerwell
Utilization review nurse job in Raleigh, NC
**Become a part of our caring community and help us put health first** Healthcare isn't just about health anymore. It's about caring for family, friends, finances, and personal life goals. It's about living life fully. At Conviva, a wholly-owned subsidiary of Humana, Inc., we want to help people everywhere, including our team members, lead their best lives. We support our team members to be happier, healthier, and more productive in their professional and personal lives. We encourage our people to build relationships that inspire, support, and challenge them. We promote lifelong well-being by giving our team members fresh perspective, new insights, and exciting opportunities to enhance their careers. At Conviva, we're seeking innovative people who want to make positive changes in their lives, the lives of our patients, and the healthcare industry as a whole.
Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others.
**Preferred Locations:** Daytona, FL, Louisville, KY, San Antonio, TX
**Use your skills to make an impact**
**Role Essentials**
+ Active Unrestricted RN license
+ Possession of or ability to obtain Compact Nursing License
+ A minimum of three years clinical RN experience;
+ Prior clinical experience, managed care experience, DME, Florida Medicaid **OR** utilization management experience
+ Demonstrates Emotional Maturity
+ Ability to work independently and within a team setting
+ Valid driver's license and/or dependable transportation necessary
+ Travel for offsite Orientation 2 to 8 weeks
+ Travel to offsite meetings up to 6 times a year as requested
+ Willing to work in multiple time zones
+ Strong written and verbal communication skills
+ Attention to detail, strong computer skills including Microsoft office products
+ Ability to work in fast paced environment
+ Ability to form positive working relationships with all internal and external customers
+ Available for On Call weekend/holiday rotation if needed
**Role Desirables**
+ Education: BSN or bachelor's degree in a related field
+ Experience with Florida Medicaid
+ Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures
+ Compact License preferred
+ Previous experience in utilization management within Insurance industry
+ Previous Medicare Advantage/Medicare/Medicaid Experience a plus
+ Current nursing experience in Hospital, SNF, LTAC, DME or Home Health.
+ Bilingual
**Additional Information**
We offer tangible and intangible benefits such as medical, dental and vision benefits, 401k with company matching, tuition reimbursement, 3 weeks paid vacation time, paid holidays, work-life balance, growth, a positive and fun culture and much more.
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
**Scheduled Weekly Hours**
40
**Pay Range**
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$71,100 - $97,800 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
**Description of Benefits**
Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 02-18-2026
**About us**
About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.
About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.
**Equal Opportunity Employer**
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options *************************************************************
$71.1k-97.8k yearly 3d ago
Utilization Review Nurse (RN)
Integrated Resources 4.5
Utilization review nurse job in Raleigh, NC
A Few Words About Us - Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.
Job Description
· The incumbent must possess medical management/clinical decision-making skills and sound skills in assessing, planning and managing member care.
· Advanced assessment and teaching skills.
· Problem solving skills.
· Familiarity with legal terminology and liability issues and ability to handle ethical or risk management issues.
· Utilization and Quality Management/Outcomes experience preferred.
· Previous work experience with a managed care organization or provider is also preferred.
· Prior experience in case management, home health, discharge planning, or Concurrent review.
Qualifications
· RN Diploma, RN Associate's degree or Bachelors of Science in Nursing (BSN) degree.
· Minimum of 3 years clinical experience in an acute medical or acute surgical setting.
· Proficiency with a Microsoft Windows operating system.
· Must have valid license to practice nursing within the US and have started application for NCnursing license.
Additional Information
With Regards,
Kavita Kumari
Allied Healthcare Recruiter
Integrated Resources, Inc
IT REHAB CLINICAL NURSING
Inc. 5000 - 2007-2014 (8th Year)
Certified MBE I GSA - Schedule 66 I GSA - Schedule 621I I GSA - Schedule 70
Tel: 732-549-2030 x208
Fax: 732-549-5549
Direct: 732-549-5302
$58k-74k yearly est. 1d ago
Senior Utility Coordinator
Stvinc
Utilization review nurse job in Raleigh, NC
STV is looking for a Senior Utility Coordinator for the Carolinas Utility Coordination group, based out of our Raleigh or Charlotte, North Carolina, offices. This position requires utility coordination experience for roadway and bridge replacement projects. STV is growing in the utility industry and needs a self-motivated, energetic employee who wants to join this high paced environment. STV is seeking a seasoned coordinator to provide support for QA/QC packages, monitor/drive project progress, and mentor junior staff.
Requirements:
It is preferred that the experience is with NCDOT and/or a similar agency.
This position would prefer someone who has extensive knowledge with whole process of utility coordination from design to construction.
It entails meeting/managing multiple utilities throughout the state of North Carolina, identifying potential utility conflicts due to roadway/bridge improvements, resolving those conflicts, commenting on schedule, and summarizing these findings to the client.
Utility coordination is more than identifying direct conflicts; It requires knowledge of construction methods for both the utilities as well as the infrastructure contractor.
This person will be responsible as the leading utility coordinator on multiple projects statewide.
This position will be responsible for training, mentoring, and monitoring junior level coordinators.
This person will assist the regional head of utility coordination with project staffing, budgets, schedules, business development, and/or client interactions.
He/She will need to be self-motivated, willing to travel (10%), and can manage schedule and budgets.
Qualifications:
Years of Experience - a minimum of 20 years of civil engineering or utility coordination experience.
Education - 2 yr associate's degree + 15 years of utility coordination experience
Experience - MicroStation/Geopak/Inroads and/or Civil 3D/AutoCAD preferred. This position requires competency in NCDOT plan reading.
Compensation Range:
$68,554.21 - $91,405.62
Don't meet every single requirement? Studies have shown that women and people of color are less likely to apply to jobs unless they meet every single qualification. At STV, we are fully committed to expanding our culture of diversity and inclusion, one that will reflect the clients we serve and the communities we work in, so if you're excited about this role but your past experience doesn't align perfectly with every qualification in the job description we encourage you to apply anyways. You may be just the right candidate for this or other roles.
STV offers the following benefits • Health insurance, including an option with a Health Savings Account • Dental insurance • Vision insurance • Flexible Spending Accounts (Healthcare, Dependent Care and Transit and Parking where applicable) • Disability insurance • Life Insurance and Accidental Death & Dismemberment • 401(k) Plan • Retirement Counseling • Employee Assistance Program • Paid Time Off (16 days) • Paid Holidays (8 days) • Back-Up Dependent Care (up to 10 days per year) • Parental Leave (up to 80 hours) • Continuing Education Program • Professional Licensure and Society Memberships
STV is committed to paying all of its employees in a fair, equitable, and transparent manner. The listed pay range is STV's good-faith salary estimate for this position. Please note that the final salary offered for this position may be outside of this published range based on many factors, including but not limited to geography, education, experience, and/or certifications.
Formulary Strategy & UtilizationReview Pharmacist
Shape the drug benefit landscape-analyze and optimize medication use.
Key Responsibilities:
Review prescribing trends and propose cost-saving alternatives.
Maintain evidence-based formularies across multiple payers.
Conduct retrospective DUR and prepare stakeholder reports.
Qualifications:
PharmD with managed care, DUR, or pharmacy benefit experience.
Strong Excel/data analytics background preferred.
Understanding of clinical guidelines and P&T processes.
Why Join Us?
Join a top-tier managed care team
Hybrid flexibility
Strategic and data-driven focus
$54k-64k yearly est. 60d+ ago
Weekend Nurse (RN) Liaison, Full-time
Hospice of Wake County Inc. 4.0
Utilization review nurse job in Raleigh, NC
Job Description
This is a full-time professional nursing position that is responsible for coordinating referrals for all Transitions LifeCare (TL) service lines and is an essential point of contact for developing and maintaining strong relationships with hospital staff and leadership. The Nurse Liaison serves as the first line point of contact for referral processing, admission coordination, and discharge planning in the hospital setting. In addition to referral coordination, the Nurse Liaison assists active TL patients with transitions of care in the hospital setting and acts as the hospice nurse case manager for active hospice patients admitted to the hospital under general inpatient level of care - this includes coordinating the hospice plan of care with hospital staff and hospice IDG members. The RN Liaison provides education and support to patients, families, hospital staff, and referral sources regarding end-of-life care and all TL services, by assisting with goals of care conversations and providing informational visits within the hospital setting as well as in other community-based locations as needed. Finally, this position partners closely with TL Provider Relations to implement results-oriented, innovative education, customer service, account management, and marketing strategies, within assigned hospitals, with the goal of providing exceptional support to referral sources and promoting excellence in end-of-life care. These duties will be performed in a manner that is consistent with Transitions LifeCare's mission statement, core values, and regulatory requirements. The schedule for this position is Saturday/Sunday/Monday 7a - 7p; one major and one minor or three minor holidays per year.
Responsibilities (what you do)
Provide informational visits, education, and support to patients and families referred for TL services in hospitals and other community-based settings, upon request.
Utilize expert-level assessment skills and critical thinking to implement on-site referral coordination for all TL service lines.
Coordinate with appropriate hospital staff to promote a seamless transition from hospital discharge back to the community setting, or hospice inpatient setting, with TL support.
Assist hospital staff and referral sources in identifying appropriate service lines and hospice level of care to provide optimal patient and family support.
Appropriately assess patients' eligibility for direct admission to the TL Hospice Home, as requested, utilizing Medicare guidelines for Hospice General Inpatient Level of Care and TL admission criteria.
Plan, provide, and document safe, competent, and compassionate nursing care to patients and families in the hospital setting in accordance with provider orders, TL established policies and procedures, and related regulatory guidelines.
Complete hospice general inpatient level of care admissions in assigned hospitals and act as hospice nurse case manager for patients under GIP level of care in the hospital setting.
Coordinate care for hospitalized hospice, palliative care, and home health patients with appropriate hospital staff and TL IDG members.
Provide emotional support to patients, families, and hospital staff coping with the challenges that accompany end of life decision making and care.
Provide approved, patient and family-centered educational resources to patients, families, and referral sources regarding all TL service lines, common end of life interventions/care, and bereavement support, as appropriate.
Provide in-service training to hospital staff regarding all TL service lines and end of life care, as assigned.
Work collaboratively with TL Provider Relations to provide education and promote TL services within targeted facilities with the goal of increasing referrals, length of stay, and daily census.
Assist in fielding, documenting, and addressing patient, family, or referral source feedback. Work to resolve any concerns in a timely manner and communicate resolution to appropriate parties.
Continue personal, professional development by maintaining required competencies, participating in continuing education, and identifying learning opportunities by seeking appropriate assistance or education offerings.
Participate in the identification of clinical or operational performance improvement opportunities and participate in organizational performance improvement initiatives.
Actively participate in the orientation and training of new employees of all disciplines.
Perform other duties, as assigned, by the Nurse Liaison Team Leader.
Expectations how you do it
Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment
Requirements (what you need)
Requires expert level analysis of patient clinical information and formulation of an accurate assessment of the patient and his/her condition.
Ability to independently seek out resources and work collaboratively to achieve goals/objectives.
Strong critical thinking, communication and organizational skills required to be effective in this role.
Proven ability to prioritize workflow and multitask with excellent time management skills.
Solid work history demonstrating robust interpersonal skills.
Strong computer skills required; experience with Netsmart, Outlook, and Office 365 preferred.
Registered Nurse with current NC license; BSN preferred.
Minimum 2 years recent clinical experience. Hospice and/or home health or nursing home experience or equivalent preferred.
Workdays and scheduled hours with weekend and holiday commitments as outlined in Employee Information Agreement.
Broad knowledge of hospice, home health, palliative care, and private duty services, reimbursement considerations, and related regulations/standards.
Current CPR certification.
Must have and maintain a valid North Carolina Driver's License, maintain automobile insurance coverage and have access to reliable transportation.
Must be able to travel to, enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
May be required to lift and/or carry items up to 50 pounds.
Must have sensory abilities to complete physical assessment, communicate with patient/family care providers and physician and to complete the reporting and follow-up documentation responsibilities of the job.
$56k-70k yearly est. 10d ago
Nurse Case Manager II
Elevance Health
Utilization review nurse job in Durham, NC
**Location** : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
**_Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law._**
**Work Schedule:** Monday to Friday from 11:30 AM to 8:00 PM EST.
**_***This position requires an on-line pre-employment skills assessment. The assessment is free of charge and can be taken from any PC with Internet access. Candidates who meet the minimum requirements will be contacted via email with instructions. In order to move forward in the process, you must complete the assessment within 48 hours of receipt and meet the criteria._**
The **Nurse Case Manager II** is responsible for care management within the scope of licensures for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Perform duties telephonically or on-site such as at hospitals for discharge planning.
**How you will make an impact:**
+ Ensures member access to services appropriate to their health needs.
+ Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
+ Implement care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
+ Coordinates internal and external resources to meet identified needs.
+ Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
+ Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
+ Negotiate rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues.
+ Assists with development of utilization/care management policies and procedures.
**Minimum Requirements:**
+ Requires BA/BS in a health-related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
+ Current unrestricted RN license in applicable state(s) required.
+ Multi-state licensure is required if this individual provides services in multiple states.
**Preferred Experience, Skills, and Capabilities:**
+ Case Management experience preferred.
+ Certification as a Case Manager preferred.
+ Managed Care experience preferred.
+ Ability to talk and type at the same time preferred.
+ Demonstrate critical thinking skills when interacting with members preferred.
+ Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly preferred.
+ Ability to manage, review and respond to emails/instant messages in a timely fashion preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $76,944 to $120,912.
Locations: Colorado; Illinois; Nevada
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
$76.9k-120.9k yearly 54d ago
Nurse Consultant
Nc State Highway Patrol
Utilization review nurse job in Nashville, NC
Agency
Office of State Human Resources
Division
Temporary Solutions
Job Classification Title
Nurse Consultant I (S)
Number
Grade
MH16
About Us
To provide a solid Human Resource management foundation, responsible oversight, and creative solutions through a collaborative approach with all stakeholders to maximize the potential of our greatest asset - OUR EMPLOYEES.
Description of Work
Knowledge Skills and Abilities/Management Preferences
This is a temporary position and there are no leave or retirement benefits offered with this position. Temporary employees who work an annual average of 30 or more hours per week may be eligible for health insurance coverage under the High Deductible Health Plan (HDHP). For more information on Health Benefits offered visit **************
Visit **************************** for employment information.
Note: Permanent and time-limited NC State Government employees must separate from their permanent or time-limited position in order to work in a temporary position. All temporary employees are limited to one NC State Government temporary assignment at a time.
Individuals hired into a temporary State job must be fully qualified for the job. OSHR supports the Governor's Job Ready initiative and seeks to expand a temporary skill set to enhance their qualifications for State government and private sector jobs. Exposure to an agency's culture, process, procedures, and potential learning opportunities can provide valuable experience to those who may seek permanent employment with the state.
This temporary position is located in Rocky Mount - Nash County.
Job Order Hourly Rate of Pay: $45.00 (Based on education and/or years of relevant work experience reflected on the application).
Basic knowledge of nursing principles and techniques for medical, surgical and mental health practices. Working knowledge of principles and practices of state and federal laws standards, certifying and accrediting bodies, guidelines, and regulations applicable to area of assignment. Working knowledge of adult learning principles and teaching techniques. Working knowledge of performance improvement principles. Ability to gather, compile, and perform preliminary analysis on data. Ability to provide patient and family education on disease processes, treatment and self-care and ability to provide feedback and guidance/counsel to nursing staff on care rendered to patients. Ability to effectively teach nursing staff and other employees as appropriate through orientation and on-the-job training. Ability to work in partnership with facilities/supervisory and management staff and outside organizations in planning, scheduling and providing service. Ability to effectively communicate information to patients, families and staff in a concise and descriptive manner verbally and in written form. Ability to engage in public speaking.
Effective July 1, 2025, candidates now meet the minimum qualifications of a position if they have the minimum education and experience listed from the class specification. The Knowledge, Skills, and Abilities listed within this vacancy announcement will be used only as management preferences and will be used to screen for the most qualified pool of applicants.
Minimum Education and Experience
Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details.
Licensed to practice as a Registered Nurse in the State of North Carolina and one year of experience in the area of specialization.
EEO Statement
The State of North Carolina is an Equal Employment Opportunity Employer and dedicated to providing employees with a work environment free from all forms of unlawful employment discrimination, harassment, or retaliation. The state provides reasonable accommodation to employees and applicants with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for religious beliefs, observances, and practices.
Recruiter:
Heather Hooks Garrett
Recruiter Email:
$45 hourly Auto-Apply 60d+ ago
Telehealth Nurse
Actalent
Utilization review nurse job in Cary, NC
We are seeking a dedicated Telehealth Registered Nurse to counsel and educate patients on specialty drug therapies, ensuring adherence to contracted and accrediting regulations. This role involves thorough and accurate documentation, discussing side effects with patients, and identifying and reporting adverse events and product complaints to the relevant authorities.
Responsibilities
+ Counsel and educate new and existing patients on specialty drug therapies.
+ Ensure adherence to contracted and accrediting regulations as indicated by drug specification.
+ Complete thorough and accurate documentation using good documentation practices and compliance with industry standards and regulations.
+ Discuss potential and current side effects with patients to educate them about treatment alternatives and facilitate ongoing therapy adherence.
+ Identify and report adverse events and product complaints to the manufacturer, FDA, and/or other governing authorities.
Essential Skills
+ Telehealth expertise.
+ Triage and acute care experience.
+ Oncology nursing experience.
+ Registered Nurse (RN) license.
+ Utilization management skills.
+ Patient education proficiency.
+ Must be an RN licensed in North Carolina with a multi-state compact nursing license.
+ At least 5 years of nursing experience.
Additional Skills & Qualifications
+ Associate, Bachelor, or higher in Nursing or accredited nursing diploma.
+ Graduate of an accredited school of nursing with 3-5 years or more post-graduate experience in pharmacy operations and patient care.
+ 5 or more years of nursing experience with at least 1 year of acute inpatient care preferred.
+ Ability to obtain licensing in all states and United States territories serviced within 3 months of employment.
+ Proficient in computer skills including e-mail, word processing, spreadsheet, and web-based programs.
+ Effective communication skills, both oral and written.
+ Experience with motivational interviewing is preferred.
+ Ability to read, analyze, and interpret practice standards, professional journals, technical procedures, and government standards and regulations.
Work Environment
You will work with a large healthcare leader within patient care and access. The working hours are Monday to Friday, from 9 am to 6 pm, with a 1-hour lunch break. The position requires a valid North Carolina multi-state nursing license with no restrictions. OSW will be trained with a preceptor and will have the opportunity to participate in various work activities.
Job Type & Location
This is a Contract to Hire position based out of Cary, NC.
Pay and Benefits
The pay range for this position is $41.00 - $41.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a hybrid position in Cary,NC.
Application Deadline
This position is anticipated to close on Jan 29, 2026.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.
$41-41 hourly 3d ago
Regional Nurse
Calyx Living
Utilization review nurse job in Raleigh, NC
Job Description
Regional Nurse
Calyx Living is actively looking to grow our regional clinical team by hiring an experienced, hands-on Regional Nurse for our assisted living communities located throughout the Raleigh Durham triangle area, with additional new communities under development in the area as well.
A Calyx Regional Nurse has primary responsibility for the oversight and maintenance of regulatory and clinical operational compliances at the communities. The Regional Nurse also serves as a resource and a mentor to the community's Resident Care Director, and assists the Resident Care Director in ensuring staffing, conducting training and ensuring compliance with all Carillon policies, processes and procedures impacting the delivery of quality resident care. Regional Nurses also serve as the Resident Care Director during times of role vacancy.
Regional Nurse Qualifications:
RN nursing license in the state of North Carolina that is listed in good standing with the NC Board of Nursing required
Minimum of three years nursing experience, with long-term care experience preferred
Ability to be on site at any community in the Triangle during normal business hours
Supervisory experience preferred
Clinical quality experience a plus
If you have strong leadership, quality assurance and clinical nursing experience and are interested in being a Regional Nurse for a successful, expanding organization, please apply here.
Job Posted by ApplicantPro
$38k-63k yearly est. 2d ago
Nurse Navigator
Rezilient Health
Utilization review nurse job in Raleigh, NC
As a Nurse Navigator at Rezilient Health, you will play a critical role in supporting patients, providers, and partners throughout the care continuum. You will lead the clinical onboarding of new contracts, manage complex tasks, coordinate referrals and authorizations, and ensure seamless communication between all stakeholders. Your work will directly impact patient outcomes, operational efficiency, and the overall success of our innovative Cloud Clinic model.
At Rezilient, we're dedicated to revolutionizing primary and specialty care by delivering convenient, timely, and seamless access to healthcare. Our innovative hybrid CloudClinic model, powered by our onsite team of Medics and virtual Providers fosters a personalized and digital healthcare experience, putting the patient at the center of their care. By leveraging cutting-edge technology, we streamline care delivery, allowing our Providers to focus on patient well-being, and we continuously expand our specialty services to provide the most comprehensive and convenient healthcare possible.
Requirements
Care Navigation & Patient Advocacy
Coordinate and manage patient referrals, including high-priority cases, ensuring timely follow-up and resolution of health concerns.
Serve as a patient advocate by facilitating communication between patients, families, providers, and payers to optimize health benefits.
Communicate proactively with patients to provide updates, answer questions, and accommodate preferences related to referrals, orders, and care navigation.
Identify and address barriers to care (e.g., transportation, financial, language, or health literacy challenges) and proactively support development of solutions to ensure patients receive timely, appropriate services.
Maintain organized, accurate, and detailed records of all care coordination activities in accordance with HIPAA and all applicable privacy regulations.
Care Coordination & Prior Authorizations
Lead and manage prior authorization processes end-to-end, including peer-to-peer reviews, insurance rebuttal letters, single case agreements, and coordination with plan representatives.
Facilitate the retrieval and secure transfer of medical records from previous specialists, manage release of information forms, and ensure all necessary documentation is available for patient care.
Conduct comprehensive insurance benefit reviews for employer plans, documenting coverage for preventative services, behavioral health, specialty care, and pharmacy needs.
Monitor and track the status of authorizations, referrals, and orders to ensure timely completion.
Navigate provider orders based on patient health plans and insurance networks on behalf of patients.
Stakeholder & Partner Collaboration
Serve as the liaison with point solutions and cost containment partners, ensuring training, logins, and functionality are established.
Collaborate with clinical teams, providers, and external partners to coordinate patient referrals, orders, and procedures in accordance with medical plan benefits and evidence-based guidelines.
Communicate with insurance administrators and healthcare facilities to verify provider participation, coverage, pre-authorization requirements, and scheduling availability.
Build and maintain strong working relationships with internal and external partners to facilitate seamless care transitions.
Process Improvement & Training
Provide input to care coordination workflows, training materials, and standard operating procedures.
Assist in building and maintaining databases of preferred specialty providers for all contracts, ensuring up-to-date and accurate information.
Qualifications
Required:
Nursing degree, RN or paramedic license, or Medical Assistant certification required
Minimum 3 years of experience in care coordination, care and/or case management
Strong knowledge of insurance benefits, prior authorizations, and referral management
Excellent organizational, problem-solving, and communication skills
Demonstrated ability to manage multiple priorities in a fast-paced, evolving environment
Proficiency with EHR systems, payer portals, and standard office software
Preferred:
Certified Case Manager (CCM) certification
Experience in a startup or high-growth healthcare technology environment
Prior experience as a Medical assistant and/or Billing and Coding
Benefits
This opportunity offers the chance to shape the future of healthcare in a culture where your ideas and contributions have a meaningful impact on the organization's future. You'll be part of a supportive, collaborative, and diverse team, with competitive compensation and benefits that include generous PTO, paid family leave, comprehensive medical, dental, vision, and life insurance, as well as stock options.
Rezilient is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other legally protected characteristic. We believe in building a diverse workforce and encourage individuals from all backgrounds to apply.
$38k-63k yearly est. Auto-Apply 33d ago
Nursing - L&D
Granville Medical Center 4.2
Utilization review nurse job in Oxford, NC
Travel L&D RN is needed for 13 weeks to start ASAP in a facility in North Carolina. Shifts consist of nights 7pm-7am. BLS, NRP, and Intermediate or Advanced AWHONN. Must have the NC license or comapct license to be considered. To speak with a recruiter please call Ventura Medstaff today at **************.
$41k-59k yearly est. 2d ago
Regional Nurse
Carillon Assisted Living 3.8
Utilization review nurse job in Fuquay-Varina, NC
Job Description
Regional Nurse
Carillon Assisted Living is actively looking to grow our regional clinical team by hiring an experienced, hands-on Regional Nurse for our assisted living communities located throughout the Raleigh Durham triangle area, with additional new communities under development in the area as well.
A Carillon Regional Nurse has primary responsibility for the oversight and maintenance of regulatory and clinical operational compliances at the communities. The Regional Nurse also serves as a resource and a mentor to the community's Resident Care Director, and assists the Resident Care Director in ensuring staffing, conducting training and ensuring compliance with all Carillon policies, processes and procedures impacting the delivery of quality resident care. Regional Nurses also serve as the Resident Care Director during times of role vacancy.
Regional Nurse Qualifications:
RN nursing license in the state of North Carolina that is listed in good standing with the NC Board of Nursing required
Minimum of three years nursing experience, with long-term care experience preferred
Ability to be on site at any community in the Triangle during normal business hours
Supervisory experience preferred
Clinical quality experience a plus
If you have strong leadership, quality assurance and clinical nursing experience and are interested in being a Regional Nurse for a successful, expanding organization, please apply here.
Job Posted by ApplicantPro
$42k-57k yearly est. 2d ago
Full-Time Infusion Nurse (RN) - Durham/Cary, NC
Local Infusion
Utilization review nurse job in Durham, NC
We are Local Infusion.
Local Infusion is a venture-backed healthcare company shaping the way care is delivered to patients with chronic autoimmune disease on specialty infusion medications. Our focus on patient experience, technology, and clinical integration allows us to deliver a differentiated care model that leads to lower costs for patients and enhanced outcomes. Through a blend of patient-centered design and a people-first team culture, Local Infusion puts the "local feel" of community, comfort and connection back into the patient and provider experience. At our care centers, all patients-and our team-can feel truly supported, every step of the way.
What We're About
We're a team of innovators, clinicians, and technologists on a mission to improve outcomes for patients, save time for physicians and make infusion therapy more affordable for everyone involved. Our mission is to transform the infusion care industry, because patients deserve better.
Ownership-Takes initiative, being accountable and caring about the outcome
Excellence-Do what it takes to raise the bar, being an example for our colleagues, patients and partners
Getting to Yes- There will be obstacles, but we find a way, even when there isn't a defined road forward
Curious & Inquisitive- Always seek to gather information and knowledge, and understand the way
It's a Marathon, not a Sprint - We have large problems to solve, and they won't be solved overnight. We are persistent every day.
We're looking for an Infusion Nurse who is passionate about raising the bar in infusion therapy care.
The Infusion Nurse will contribute to the company's growth by providing direct patient care at one or several of our centers in Maryland. The Infusion Nurse will make sure our patients receive the highest level of care possible in infusion therapy.
The ideal candidate has experience working autonomously, and experience starting IVs and working with biologic drugs. The Infusion Nurse role is perfect for those wishing to remain at the forefront of healthcare innovation, while having predictable hours, autonomy, and a manageable workload (always a 3:1 patient to clinician ratio).
In this role, you will:
Assess and document the health status of the patient
Deliver infusions or injections in accordance with prescribed protocols and organization guidelines
Assist in maintaining medical inventory and supplies
Openly communicate with referring/prescribing providers, such as order clarification, patient status, and plan of care
Provide onsite supervision for all patients
Ability to work one Saturday a month
Here's what we're looking for:
Current RN licensure in Maryland
ACLS & PALS Certification (preferred)
Current BLS CPR certification
Excellent IV skills (infusion therapy experience a plus)
Experience and strong familiarity utilizing Electronic Health Records (EHR) systems
Ability to work 1 Saturday a month
The Local Infusion Way
Local Infusion is a respectful upbeat team united by our mission of shaping the way specialty infusion care is delivered. We are highly ambitious but understand that in order to do a great job, we have to take care of ourselves; we expect that you will have time and energy devoted to your families, friends and hobbies.
As part of our team, full-time employees get:
Medical, dental, and vision insurance through our employer plan
Short and long-term disability coverage
401(k) - as an early-stage startup, and we match!
15 Days PTO - and we want you to take it!
Competitive paid parental leave and flexible return to work policy.
We invest in your career. Our company is growing quickly, and we'll give you the opportunity to do the same. You'll have access to a number of professional development opportunities so that you can keep up with the company's evolving needs and grow your career along the way.
We don't discriminate-Local Infusion is an Equal Employment Opportunity (EEO) Employer. We fundamentally believe that a more diverse and inclusive team leads to a stronger company more able to achieve our vision.
$38k-63k yearly est. Auto-Apply 30d ago
NP or PA Part-time Weekday Hours (NO WEEKENDS) - 24 Hours Weekly
American Family Care Dunn 3.8
Utilization review nurse job in Dunn, NC
Benefits/Perks
Retirement benefits
Provider Bonus Plan
Great small business work environment
Flexible scheduling
UpToDate Access
Medical Malpractice Coverage
Job SummaryThe Advanced Practice Provider (APP) cares for our patients within the scope of training and approved the agreement, as outlined by their governing board. Works collaboratively with other providers and staff to ensure efficient patient flow and a high level of patient satisfaction. This position works directly with a franchised business location. The specific job duties and benefits can vary between franchises. Responsibilities
Perform complete, detailed, and accurate health histories, review patient records, develop comprehensive medical assessments, and order laboratory, radiological and diagnostic studies appropriate for complaint, race, sex, and physical condition of the patient
Formulate medical and nursing diagnoses and institute therapy or referrals of patients to the appropriate health care facilities, agencies, and other resources of the community or physician
Institute emergency measures and emergency treatment or appropriate stabilization measures in situations such as cardiac arrest, shock, hemorrhage, convulsions, poisoning, and allergic reactions
Interpret and analyze patient data to determine patient status, patient management and treatment
Provide instructions and guidance regarding health care and health care promotion to patients/family/ significant others
Other duties and responsibilities as assigned
Qualifications
Excellent communicator with staff, patients, and family
Professional appearance and attitude
ANCC, AANP, or NCCPA Board Certified - (with 1 yr ER/UC experience preferred)
Active and current Physician Assistant or Nurse Practitioner licensure in the state of practice, DEA number, and state-controlled substance certificate, as required
Able to multi-task and work independently
Company OverviewAmerican Family Care (AFC) is one of the largest primary and urgent care companies in the U.S., providing services seven days a week on a walk-in basis. Our state-of-the-art centers focus on the episodic treatment of acute illnesses and injuries, workers' compensation, and occupational medicine. Each location is equipped with an onsite lab and in-house x-ray capability. AFC is the parent company of AFC Franchising, LLC (AFCF).
PS: It's All About You!
American Family Care has pioneered the concept of convenient, patient-centric healthcare. Today, with more than 250 clinics and 800 in-network physicians caring for over 6 million patients a year, AFC is the nation's leading provider of urgent care, accessible primary care, and occupational medicine. Ranked by Inc. magazine as one of the fastest-growing companies in the U.S., AFC's stated mission is to provide the best healthcare possible, in a kind and caring environment, while respecting the rights of all patients, in an economical manner, at times and locations convenient to the patient.
If you are looking for an opportunity where you can make a difference in the lives of others, join us on our mission. We invite you to grow with us and experience for yourself the satisfying and fulfilling work that the healthcare industry provides.
Please note that a position may be for a company-owned or franchise location. Each franchise-owned and operated location recruits, hires, trains, and manages their own employees, sets their own employment policies and procedures, and provides compensation and benefits determined by that franchise owner. Company-owned locations provide a comprehensive benefits package including medical, dental, vision, disability, life insurance, matching 401(k), and more.
We are an Equal Opportunity Employer.
$37k-58k yearly est. Auto-Apply 60d+ ago
Nursing - SNF
Person Memorial Hospital
Utilization review nurse job in Roxboro, NC
Are you ready to take your Travel career to the next level? See places you have not seen before? Ventura's MedStaff tenured Recruiters are here to help you find your ideal contract; with over 50 years of combined experience. Markets have changed, but Ventura MedStaff has maintained a leader in the forefront of Therapy, Allied and Nursing opportunities. Our recruiters are here to help answer your questions and provide you with the most up to date information. Contracts run 8-13 weeks, with 36-40-hour guarantees, flexible start dates, and a mix of schedules. Contact one of our dedicated Recruiters to discuss more details.
Ventura MedStaff benefits represent the care and compassion we provide for our clients.
• Health, dental, vision, life, disability benefits and 401k
• Tax free stipends when applicable
• Gym discounts
• Weekly pay
• $750.00 referral bonus
Please apply or contract us at: *********************** or ************
$38k-64k yearly est. 18d ago
Nursing - ER
Cape Fear Valley Betsy Johnson Hospital 4.8
Utilization review nurse job in Dunn, NC
Travel ER RN is needed to start in a facility in North Carolina. NC or compact license is required. Certifications required are ACLS, BLS, and PALS. 12 hour shifts with every other weekend and holiday. To speak with a recruiter please call Ventura Medstaff today at **************.
$45k-66k yearly est. 1d ago
Drug Utilization Review Pharmacist
Pharmacy Careers 4.3
Utilization review nurse job in Raleigh, NC
Drug UtilizationReview Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug UtilizationReview (DUR) Pharmacist to support quality prescribing and improve patient outcomes. This role is ideal for pharmacists who enjoy analyzing medication use, applying clinical guidelines, and collaborating with providers to promote safe, cost-effective care.
Key Responsibilities
Conduct prospective, concurrent, and retrospective drug utilizationreviews.
Evaluate prescribing patterns against clinical guidelines and formulary criteria.
Identify potential drug interactions, duplications, and inappropriate therapy.
Prepare recommendations for prescribers to optimize therapy and reduce risk.
Document reviews and ensure compliance with state, federal, and health plan requirements.
Contribute to quality improvement initiatives and pharmacy program development.
What You'll Bring
Education: Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree.
Licensure: Active and unrestricted pharmacist license in the U.S.
Experience: Managed care, PBM, or health plan experience preferred - but hospital and retail pharmacists with strong clinical skills are encouraged to apply.
Skills: Analytical mindset, detail-oriented, and excellent written and verbal communication.
Why This Role?
Impact: Shape prescribing decisions that affect thousands of patients.
Growth: Build expertise in managed care and population health pharmacy.
Flexibility: Many DUR roles offer hybrid or fully remote schedules.
Rewards: Competitive salary, benefits, and career advancement opportunities.
About Us
We are a confidential healthcare partner providing managed care pharmacy services nationwide. Our DUR pharmacists play a key role in ensuring that medications are used safely, appropriately, and cost-effectively across diverse patient populations.
Apply Today
Advance your career in managed care pharmacy - apply now for our Drug UtilizationReview Pharmacist opening and help lead the way in improving medication safety and outcomes.
$54k-64k yearly est. 60d+ ago
Nurse Case Manager II
Elevance Health
Utilization review nurse job in Durham, NC
Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
Work Schedule: Monday to Friday from 11:30 AM to 8:00 PM EST.
* This position requires an on-line pre-employment skills assessment. The assessment is free of charge and can be taken from any PC with Internet access. Candidates who meet the minimum requirements will be contacted via email with instructions. In order to move forward in the process, you must complete the assessment within 48 hours of receipt and meet the criteria.
The Nurse Case Manager II is responsible for care management within the scope of licensures for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Perform duties telephonically or on-site such as at hospitals for discharge planning.
How you will make an impact:
* Ensures member access to services appropriate to their health needs.
* Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
* Implement care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
* Coordinates internal and external resources to meet identified needs.
* Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
* Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
* Negotiate rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues.
* Assists with development of utilization/care management policies and procedures.
Minimum Requirements:
* Requires BA/BS in a health-related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
* Current unrestricted RN license in applicable state(s) required.
* Multi-state licensure is required if this individual provides services in multiple states.
Preferred Experience, Skills, and Capabilities:
* Case Management experience preferred.
* Certification as a Case Manager preferred.
* Managed Care experience preferred.
* Ability to talk and type at the same time preferred.
* Demonstrate critical thinking skills when interacting with members preferred.
* Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly preferred.
* Ability to manage, review and respond to emails/instant messages in a timely fashion preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $76,944 to $120,912.
Locations: Colorado; Illinois; Nevada
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Job Level:
Non-Management Exempt
Workshift:
Job Family:
MED > Licensed Nurse
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
How much does a utilization review nurse earn in Raleigh, NC?
The average utilization review nurse in Raleigh, NC earns between $44,000 and $80,000 annually. This compares to the national average utilization review nurse range of $47,000 to $89,000.
Average utilization review nurse salary in Raleigh, NC
$60,000
What are the biggest employers of Utilization Review Nurses in Raleigh, NC?
The biggest employers of Utilization Review Nurses in Raleigh, NC are: