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Insurance Nurse Reviewer Jobs in Wisconsin (NOW HIRING)

Gainwell Technologies

WI · On-site

$78 - $85/hr

Virtual (Exception only) Summary We are seeking a talented individual for a Nurse Reviewer ... insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations ...

New

Integrated Resources INC

HEDIS Record Reviewer

Milwaukee, WI · On-site

$29.75 - $39.50/hr

Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing. The HEDIS ... insurance coverage limits is also required. Additional Information Kind Regards, Kavita Kumari ...

Adaptive Home Health, LLC

WI · On-site

$75 - $100/hr

... review. * Provide patient and caregiver education (teach‑back) aligned to the plan of care ... Health, dental, vision, and life insurance * Paid time off * Flexible scheduling * Referral program ...

New

Osceola-Medical-Center

WI · On-site

$75 - $105/hr

Serve as liaison between the hospital, physicians, and insurance providers regarding utilization ... Utilization Review RN functions in a collaborative clinical and administrative environment ...

New

Copperas Hollow Nursing

WI · On-site

$65 - $85/hr

Review lab results and respond to signs of infection * Educate staff on wound prevention and ... Health, Dental, and Vision Insurance * Extra Protection : AD&D, Short-Term Disability, Cardiac ...

New

Eagle Crest Communities

Nurse - LPN or RN

La Crosse, WI · On-site

$39.50/hr

We'll review your wage at 6 months - we pay forhigh performance! Our Benefits * Available at 50 ... HealthInsurance, Health Reimbursement Account, Dental Insurance, Life and AD&DInsurance, Long Term ...

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Insurance Nurse Reviewer information

What is an insurance nurse reviewer?

An Insurance Nurse Reviewer is a licensed nurse who evaluates medical claims to ensure they meet policy guidelines and medical necessity. They review patient records, treatment plans, and healthcare provider documentation to determine coverage eligibility. Their role helps insurance companies manage costs while ensuring patients receive appropriate care. Strong clinical knowledge and attention to detail are essential for assessing claims accurately.

What does an insurance nurse reviewer do?

On a typical day, an Insurance Nurse Reviewer spends much of their time reviewing patient medical records, evaluating insurance claims for medical necessity, and documenting their findings in detail. The role often involves collaborating with physicians, case managers, and adjusters to clarify information or seek additional insights when necessary. You may also participate in team meetings to discuss complex cases, ensure adherence to regulatory standards, and stay current with evolving policies. The work is largely independent but requires strong communication skills and a systematic approach to managing multiple cases effectively.

What are the key skills and qualifications needed to thrive as an insurance nurse reviewer?

To thrive as an Insurance Nurse Reviewer, you need a current nursing license, clinical experience, and a strong understanding of medical terminology and claims review processes. Familiarity with utilization review software, health insurance claims systems, and URAC or CM certification is often required. Attention to detail, critical thinking, and effective written and verbal communication skills help you excel in this position. These qualifications and abilities are vital for accurately evaluating medical records, ensuring compliance, and making informed decisions regarding healthcare coverage.

What are popular job titles related to Insurance Nurse Reviewer jobs in Wisconsin?

For Insurance Nurse Reviewer jobs in Wisconsin, the most frequently searched job titles are:

What job categories do people searching Insurance Nurse Reviewer jobs in Wisconsin look for?

The top searched job categories for Insurance Nurse Reviewer jobs in Wisconsin are:

Insurance Nurse Reviewer jobs near you
Infographic showing various Insurance Nurse Reviewer job openings in Wisconsin as of August 2026, with employment types broken down into 91% Full Time, 4% Part Time, and 5% Contract. Highlights an 95% In-person, and 5% Remote job distribution.

Nurse Reviewer - Itemized Bill Review

Gainwell Technologies

WI • On-site

$78 - $85/hr

Other

Medical, Life, Retirement, PTO

Posted 2 days ago

New

Gainwell Technologies rating

7.8

Company rating: 7.8 out of 10

Based on 83 frontline employees who took The Breakroom Quiz

138th of 247 rated software companies

Job description

Location: Any city, TX, US, 99999

Work Mode: Virtual (Exception only)

Summary

We are seeking a talented individual for a Nurse Reviewer - Itemized Bill Review role to perform reviews of medical records, healthcare claims, itemized medical bills, and UB‑04 forms to ensure accuracy, compliance, and proper billing practices. This position requires clinical review expertise as well as experience with itemized bill review.

Your role in our mission
  • Review medical claims using the UB‑04 and detailed itemized statements to validate line‑item charges.
  • Verify accuracy of itemized charges in accordance with client policy and industry standards.
  • Perform level‑of‑care and utilization reviews by analyzing medical records and comparing them against criteria to determine appropriateness and reasonableness of care.
  • Apply critical thinking and decision‑making skills to determine whether medical record documentation supports the need for services while meeting production goals and quality standards.
  • Assist management with training new reviewers, including daily monitoring, mentoring, feedback, and education.
  • Maintain current knowledge of clinical criteria guidelines and/or coding guidelines; complete required CEUs to maintain RN licensure.
  • Attend training and scheduled meetings to enhance knowledge of clinical policies, procedures, rules, and regulations.
  • Actively cross‑train to perform reviews of multiple claim types to support a flexible workforce that meets client needs.
What we're looking for
  • Active, unrestricted RN license in the United States and in the primary state of residence; active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) required.
  • 5+ years of clinical experience in an inpatient hospital setting required.
  • 1+ year of itemized bill review experience required.
  • 3+ years of utilization review or claims auditing experience preferred.
  • Experience with CPT, ICD‑10, and HCPCS coding guidelines.
  • Experience using MCG or InterQual criteria preferred.
  • Ability to multitask in a fast‑paced production environment.
What you should expect in this role
  • This is a home‑based position, and you must have a work location within the continental United States.
  • You must provide a high‑speed internet connection and maintain a work environment free from distractions.
  • Ability to work during normal business hours, as this role requires frequent interaction with the team and other departments.
  • May be required to work extended hours for special business needs.
  • May be required to travel at least 10% of the time based on business needs.

This position is for pipeline purposes, and we welcome applications on an ongoing basis.

The pay range for this position is $78,000.00 - $85,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job‑related knowledge, skills, and experience among other factors. All salaried, full‑time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

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What Gainwell Technologies employees say

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Hours and flexibility

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About Gainwell Technologies

Sourced by ZipRecruiter

With Health and Cost outcomes that pierce Inequities and Impact Economies, the success of our Nation’s Federal Medicaid program is inextricably tied to the Prosperity of Communities, States and the Nation as a whole. We think that deserves Respect and a Commitment from Innovators who can help those who operate within and around health and human services evolve to meet their goals. At Gainwell, that’s our Sole focus. Built across more than Five Decades, Gainwell has intentionally seized opportunities to advance its digitally enabled services to meet Agencies, Health plans and MCOs where they are on their modernization journeys and propel them into the future of Healthcare. Equally important to our Expanding Technologies and Results. We bring ideas that bring policies to life.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Irving, TX, US

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