Top 35 Rn clinical value analysis Jobs in Wisconsin

RN Readmission Manager, Payment Integrity
Centene Corporation —Wisconsin
- $87,700 - $157,800 a year
- Full-time
- Remote
- Nursing
- RN License
- 3 years
- Paid holidays
- Health insurance
7d
RN, Nursing Informatics Specialist
Froedtert Health —Milwaukee, WI
- Full-time
- Nursing
- RN License
- Mid-level
- Continuing education credits
- Disability insurance
Home Health RN Case Manager
UW Health Care Direct —Middleton, WI
- $77,355.20 - $114,233.60 a year
- Weekends as needed
- CPR Certification
- Nursing
- RN License
- AD&D insurance
- Disability insurance
Quick Apply
Registered Nurse, RN - Quality Improvement Specialist
Gundersen Health System —La Crosse, WI
- From $81,244.80 a year
- Full-time
- CPR Certification
- Nursing
- RN License
- Retirement plan
Per Diem Clinical Research Nurse - Home Visits
Science 37 —Milwaukee, WI
- $50 - $55 an hour
- Nights as needed
- Nursing
- RN License
- BLS Certification
21h
Quality Resource Specialist
Bellin Health —Green Bay, WI
- Full-time
- RN License
- Mid-level
- Bachelor's degree
- Health insurance
- Tuition reimbursement
14d
Health and Wellness Educator
Mercy Health System Corporation —Janesville, WI
- $49,199.25 - $78,718.81 a year
- Full-time
- Microsoft Outlook
- Mid-level
- LPN
- Paid parental leave
- Health savings account
Quick Apply
RN-School Nurse - Palmyra Eagle Area School District
Fort Healthcare Inc —Fort Atkinson, WI
- Part-time
- School experience
- Nursing
- RN License
- Free parking
- Disability insurance
Program Manager | General Surgery Services
Gundersen Health System —La Crosse, WI
- From $74,000 a year
- Full-time
- Surgery
- RN License
- 3 years
- Wellness program
- Health savings account
7d
FRAUD WASTE ABUSE ANALYST - ASPIRUS HEALTH PLAN
ASPIRUS HEALTH —Wausau, WI
- Full-time
- RN License
- Mid-level
- Analysis skills
- Wellness program
- Retirement plan
Supervisor, Nursing Ambulatory Service (Complex Care)
Children's Wisconsin —Milwaukee, WI
- Full-time
- Nursing
- RN License
- BLS Certification
NURSE EDUCATOR HOURLY - ICU / CRITICAL CARE
ASPIRUS HEALTH —Wausau, WI
- Part-time
- Background check
- CPR Certification
- Nursing
- Paid time off
- Retirement plan
Quick Apply
Home Health Visit Nurse - Weekend (0.75 FTE)
UW Health Care Direct —Middleton, WI
- $37.19 - $54.92 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- AD&D insurance
- Disability insurance
Quick Apply
11d
TRAUMA COORDINATOR - TRAUMA PROGRAM
ASPIRUS HEALTH —Woodruff, WI
- 8 hour shift
- CPR Certification
- Nursing
- RN License
Coding Coordinator
Fort Healthcare Inc —Fort Atkinson, WI
- Full-time
- Hospital
- English
- Research
- Free parking
- Disability insurance
NURSE EDUCATOR HOURLY - GENERALIST - MERRILL/WAUSAU, WI
ASPIRUS HEALTH —Wausau, WI
- Full-time
- Background check
- CPR Certification
- Nursing
- Paid time off
- Retirement plan
Quick Apply
PUBLIC HEALTH NURSE 2 and 3
City of Milwaukee —Milwaukee, WI
- $72,917 - $93,038 a year
- Weekends as needed
- Background check
- Spanish
- Nursing
- Wellness program
- COVID-19 protective measures
Advocacy Specialist-Investigator
Disability Rights Wisconsin —Milwaukee, WI
- $52,020 - $64,826 a year
- Full-time
- Microsoft Outlook
- Experience working with individuals with disabilities
- Writing skills
- Disability insurance
- Dental insurance
Quick Apply
14d
Emergency Medical Technician (EMT) - Clinic
SSM Health —Madison, WI
- Full-time
- BLS Certification
- No experience needed
- High school diploma or GED
- Paid parental leave
- Health insurance
14d
Emergency Medical Technician (EMT)
SSM Health —Madison, WI
- Full-time
- BLS Certification
- No experience needed
- High school diploma or GED
- Paid parental leave
- Health insurance

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rn clinical value analysis jobs near wisconsin

RN Readmission Manager, Payment Integrity

Centene Corporation -
Wisconsin

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Job Details

Full-time
$87,700 - $157,800 a year
7 days ago

Benefits

Paid holidays
Health insurance
401(k)
Tuition reimbursement
Paid time off

Qualifications

Medical claims processing software
Healthcare team management
Healthcare reimbursement methods
Healthcare coding investigations
Documentation reviews
DRG

Full Job Description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

A Licensed RN paired with a Coding Credential is the candidate this team is seeking for this position that will lead and oversee PI initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy. You will lead a team focused on expanded readmission reviews allowing CNC to ensure payment accuracy as well as alignment with internal policies and regulatory requirements. Experience Required for all RN's with Coding Credentials applying:

5 + years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
3+ years of people leadership experience, including direct management of teams, required.
2+ or more years of experience using Diagnosis Related Group encoder and grouper tools (for example, 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools), required.

Position Purpose:
Manages a team of auditors and clinical professionals and is accountable for audit quality, consistency, and overall program performance for potentially preventable readmissions. Oversees payer readmission review programs to ensure accurate, compliant determinations and achievement of payment integrity objectives. This role directs the identification and validation of potentially preventable readmissions while supporting appropriate reimbursement under MS-DRG and APR-DRG methodologies. Responsible for driving program results through audit oversight, trend analysis, and the development of standardized review criteria and best practices.

Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, cost avoidance, and payment accuracy, ensuring alignment with established objectives, internal policies, and regulatory requirements.
Collaborate with Health Plans, Medical Economics, Finance, Compliance, Legal, Provider Relations, and Technology teams to support the design, execution, and ongoing monitoring of readmission and DRG-related Payment Integrity strategies.
Monitor program performance against defined metrics, financial targets, and operational benchmarks, using trend analysis to identify risks, variances, and opportunities for improvement.
Provide leadership and operational oversight to teams performing readmission, MS-DRG, and APR-DRG reviews, ensuring accuracy, consistency, timeliness, and adherence to established review standards.
Ensure compliance with federal and state regulations, managed care organization requirements, contractual obligations, and internal policies governing Payment Integrity and audit activities.
Prepare and present reports, analyses, and performance summaries to leadership and key stakeholders, highlighting audit outcomes, trends, and actionable recommendations.
Identify process gaps, operational risks, and control weaknesses, and implement or recommend corrective actions to improve quality, efficiency, and program effectiveness.
Lead, coach, and develop team members by setting clear expectations, promoting accountability, and fostering a culture of collaboration, quality, and continuous improvement.
Serve as a subject matter expert for Payment Integrity practices within assigned scope, providing guidance on readmission review methodology, audit standards, and reimbursement considerations.
Performs other duties as assigned.
Complies with all policies and standards.

Education/Experience:

Bachelor’s degree in Healthcare Administration, Business, Public Health, Health Information Management, Nursing, or a related field required; an additional four (4) years of directly related experience may be considered in lieu of a degree.

5 + years of progressive experience in Payment Integrity, including readmission review and DRG validation activities, required.
3+ years of people leadership experience, including direct management of teams, required.
2+ or more years of experience using Diagnosis Related Group encoder and grouper tools (for example, 3M, Optum Encoder, TruCode, TruBridge, WebSTRAT, Payment Systems Incorporated, or similar tools), required.
Experience working with payer claims systems preferred.
Demonstrated experience supporting government programs, regulatory compliance, or audit activities preferred.
Project management experience preferred.
Experience partnering with external vendors supporting Payment Integrity audit, recovery, or edit programs preferred.
Inpatient hospital documentation improvement experience preferred.

Master’s degree preferred.

License/Certification: Active Health Information Management or coding credentials required, such as RHIT, RHIA, CCS, CIC, or CCDS or Registered Nurse licensure or higher clinical qualification, in combination with a coding credential, required.

Pay Range: $87,700.00 - $157,800.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. 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 other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Apply Now

Refine Your Search

rn clinical value analysis jobs in wisconsin

RN Readmission Manager, Payment Integrity

RN, Nursing Informatics Specialist

Home Health RN Case Manager

Registered Nurse, RN - Quality Improvement Specialist

Per Diem Clinical Research Nurse - Home Visits

Quality Resource Specialist

Health and Wellness Educator

RN-School Nurse - Palmyra Eagle Area School District

Program Manager | General Surgery Services

FRAUD WASTE ABUSE ANALYST - ASPIRUS HEALTH PLAN

Supervisor, Nursing Ambulatory Service (Complex Care)

NURSE EDUCATOR HOURLY - ICU / CRITICAL CARE

Home Health Visit Nurse - Weekend (0.75 FTE)

TRAUMA COORDINATOR - TRAUMA PROGRAM

Coding Coordinator

NURSE EDUCATOR HOURLY - GENERALIST - MERRILL/WAUSAU, WI

PUBLIC HEALTH NURSE 2 and 3

Advocacy Specialist-Investigator

Emergency Medical Technician (EMT) - Clinic

Emergency Medical Technician (EMT)

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