Top 6 Utilization review nurse Jobs in Appleton, Wi

RN Coordinator Utilization Management
Network Health, Inc —Menasha, WI
- Full-time
- Remote
- Nursing
- RN License
- Bachelor of Science
Weekend RN Coordinator Utilization Management (1.0 FTE)
Network Health, Inc —Menasha, WI
- Full-time
- Remote
- Nursing
- RN License
- Bachelor of Science
RN Care Manager
Network Health, Inc —Menasha, WI
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
Utilization Management Reviewer
Amerihealth Caritas —United States
- Full-time
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Paid holidays
- Health insurance

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RN Coordinator Utilization Management
Network Health, Inc —Menasha, WI
Collaborate with other NH departments to develop interdepartmental operational processes. Current registered nurse licensure in Wisconsin required.

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RN Coordinator Utilization Management

Network Health, Inc -
Menasha, WI

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Job Details

Full-time

Qualifications

Nursing
RN License
Associate's degree
Associate Degree in Nursing
Nursing

Full Job Description

The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on first day. Training is required in person at our Menasha location for the first 6-8 weeks.

Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday

Check out our 2025 Community Report (https://www.youtube.com/watch?v=Oea3uHW0EV0) (https://networkhealth.com/__assets/pdf/2025_annual_report.pdf) to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication
Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
Participate in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files)
Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment
Collaborate with other NH departments to develop interdepartmental operational processes
Support Utilization Management department programs and goals through active participation
Identify and screen candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria
Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
Evaluate cases for cost savings/quality improvement potential
Other duties and responsibilities as assigned

Job Requirements:

Bachelor of Science in Nursing, preferred
Associate Degree in Nursing, required
Current registered nurse licensure in Wisconsin required
Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
Experience in insurance, managed care and utilization management preferred

Network Health is an Equal Opportunity Employer

Licenses & Certifications

Preferred

Registered Nurse

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.

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Refine Your Search

utilization review nurse jobs in appleton, wi

RN Coordinator Utilization Management

Weekend RN Coordinator Utilization Management (1.0 FTE)

RN Care Manager

Utilization Management Reviewer

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