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Director Remote Utilization Review Jobs in Wisconsin

Harris

Chart Review: 8 min Outreach Attempts: 6 min Actual Call: 11 min Care Coordination: 9 min Total ... Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. * Clear ...

Harris

Chart Review: 8 min Outreach Attempts: 6 min Actual Call: 11 min Care Coordination: 9 min Total ... Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. * Clear ...

Harris

Chart Review: 8 min Outreach Attempts: 6 min Actual Call: 11 min Care Coordination: 9 min Total ... Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. * Clear ...

Harris

Chart Review: 8 min Outreach Attempts: 6 min Actual Call: 11 min Care Coordination: 9 min Total ... Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. * Clear ...

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All JobsUtilization Review JobsDirector Remote Utilization Review JobsDirector Remote Utilization Review Jobs in Wisconsin

Director Remote Utilization Review information

What is the difference between Director Remote Utilization Review vs Utilization Review Nurse?

AspectDirector Remote Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, advanced degree, and management experienceRegistered Nurse (RN) license, relevant clinical experience
Work EnvironmentOversees teams remotely, strategic planning, policy developmentConducts patient reviews, collaborates with healthcare providers, often remote or onsite
Employer & Industry UsageHealth insurance companies, managed care organizationsHospitals, insurance companies, healthcare facilities

The main difference is that the Director Remote Utilization Review focuses on managing teams and policies remotely, while the Utilization Review Nurse performs clinical reviews directly related to patient care. The director has a broader strategic role, whereas the nurse role is more clinical and operational.

What is a Director of Remote Utilization Review?

A Director of Remote Utilization Review is a healthcare leader responsible for overseeing teams that assess the necessity, appropriateness, and efficiency of medical services, typically from a remote or virtual environment. This role ensures compliance with regulatory guidelines, optimizes resource use, and helps manage healthcare costs while maintaining quality patient care. Directors collaborate with physicians, nurses, and insurance providers to review clinical cases and develop utilization review strategies. They also monitor performance metrics and implement process improvements for remote teams.

How does a Director of Remote Utilization Review typically collaborate with clinical and administrative teams to ensure effective patient care management?

A Director of Remote Utilization Review plays a pivotal role in bridging clinical staff, case managers, and administrative teams to optimize patient care and resource utilization. This is often achieved through regular virtual meetings, data sharing, and cross-departmental strategy sessions to review utilization trends and address barriers to care. The director ensures that remote teams adhere to regulatory standards and organizational goals, fostering open communication to streamline workflows and resolve complex cases efficiently. Successful collaboration enhances patient outcomes, reduces unnecessary costs, and maintains compliance, all while supporting a positive remote team environment.

What are the key skills and qualifications needed to thrive as a Director of Remote Utilization Review, and why are they important?

To thrive as a Director of Remote Utilization Review, you need in-depth knowledge of healthcare regulations, utilization management processes, and a relevant clinical background, typically supported by an RN or other clinical licensure and experience in case management. Familiarity with utilization review software, electronic health records (EHR), and certifications such as CCM or UM are often required. Leadership, analytical thinking, and strong communication skills are vital for guiding teams and collaborating with stakeholders. These skills ensure effective oversight of remote teams, regulatory compliance, and optimal patient care outcomes.
What are the most commonly searched types of Remote Utilization Review jobs in Wisconsin? The most popular types of Remote Utilization Review jobs in Wisconsin are:
What cities in Wisconsin are hiring for Director Remote Utilization Review jobs? Cities in Wisconsin with the most Director Remote Utilization Review job openings:
Director Remote Utilization Review jobs near you
Infographic showing various Director Remote Utilization Review job openings in Wisconsin as of July 2026, with employment types broken down into 100% Full Time. Highlights an 100% Remote job distribution.

Weekend Associate Medical Director - 0.3 FTE

Network Health, Inc

Brookfield, WI • On-site, Remote

Full-time

Re-posted 20 days ago

Job description

In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.

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 is required occasionally for the position.

Hours: 0.3 FTE, 24 hours per pay period, 8am - 5pm Friday through Sunday

Check out our 2025 Community Report 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:

  • Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers
  • Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards
  • Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs. In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes
  • Provide medical consultation as requested for:
    • Medical/legal issues
    • Member grievance procedures
    • Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts
    • Medical issues related to contract negotiations with health care providers
    • Determining if services to members/enrollees meet medical criteria
  • Promote positive relationship between NHP and medical community
  • Serve as liaison between NHP and providers regarding matters of medical policy and medical administration
  • Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations
  • Participates in the ongoing recruitment of plan physicians.
  • Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors
  • Assist in the development of appropriate medical guidelines and parameters for claims review
  • Assist in the training of NHP staff on matters relating to medical guidelines
  • Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness
  • Perform second level review of provider appeals and disputes
  • Serve on committees as coordinated with the CMO
  • Assist in strategic planning targeted towards plan growth initiatives

Job Requirements:

  • Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction

  • Member in good standing of the local medical community. An active practitioner of medicine in the NHP service areas

  • Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service area

  • Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity

  • Board certified in an ABMS medical specialty required

Network Health is an Equal Opportunity Employer

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