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Insurance Utilization Reviewer Jobs in Waterford, WI

UHS

Intake Coordinator

West Allis, WI · On-site

$17.50 - $24/hr

... utilization review staff, Granite Hill Hospital business office staff and clinical staff to insure continuity of communication. This position is also responsible for inquiry calls, insurance ...

DERSE INC

Human Resources Generalist

Milwaukee, WI · On-site

Annually evaluates the cost of Employee Benefits, including health care cost containment, utilization review, and insurance claim costs. * Leads strategy planning and presents the communication for ...

DERSE, Inc.

Human Resources Generalist

Milwaukee, WI · On-site

Annually evaluates the cost of Employee Benefits, including health care cost containment, utilization review, and insurance claim costs. * Leads strategy planning and presents the communication for ...

DERSE INC

Human Resources Generalist

Milwaukee, WI · On-site

Annually evaluates the cost of Employee Benefits, including health care cost containment, utilization review, and insurance claim costs. * Leads strategy planning and presents the communication for ...

CorVel Corporation

RN Field Case Manager I

Waukesha, WI · On-site

$60 - $80/hr

A cost containment background, such as utilization review or managed care is helpful * Strong ... Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. In addition ...

Foxconn WI

Test Engineer

Mount Pleasant, WI · On-site

The Test Engineer will develop plans for process optimization and test capacity utilization for ... Review current test equipment and facilities against present and future requirements to ensure test ...

Foxconn WI

Test Engineer

Mount Pleasant, WI

The Test Engineer will develop plans for process optimization and test capacity utilization for ... Review current test equipment and facilities against present and future requirements to ensure test ...

Aurora Health Care

Outpatient Therapist

Wauwatosa, WI · On-site

$60 - $80/hr

Provides case management and utilization review services for patient in his/her assigned caseload ... Serves as a liaison with these referral sources in coordination with other staff to insure ...

Foxconn WI

Test Engineer

Mount Pleasant, WI · On-site

The Test Engineer will develop plans for process optimization and test capacity utilization for ... Review current test equipment and facilities against present and future requirements to ensure test ...

Foxconn WI

Test Engineer

Mount Pleasant, WI · On-site

The Test Engineer will develop plans for process optimization and test capacity utilization for ... Review current test equipment and facilities against present and future requirements to ensure test ...

Metro Market

PHARMACY/PHARMACIST LEADER

Milwaukee, WI · On-site

$57.50 - $69/hr

... pricing and generic utilization, controlling pharmacy inventory, and providing/implementing ... insurance profitability; handle third-party problems, rejections, and audits in a timely fashion ...

Metro Market

PHARMACY/PHARMACIST LEADER

Wauwatosa, WI · On-site

$57.25 - $69/hr

D irect the pharmacy team to achieve warehouse utilization goals, avoid unnecessary overstock ... M onitor third-party or insurance profitability; handle third-party problems, rejections, and ...

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Showing results 21-40

All JobsInsurance Utilization Reviewer JobsInsurance Utilization Reviewer Jobs in Waterford, WI

Insurance Utilization Reviewer information

See Waterford, WI salary details

$30.1K

$36.9K

$42.7K

How much do insurance utilization reviewer jobs pay per year?

As of Sep 7, 2026, the average yearly pay for insurance utilization reviewer in Waterford, WI is $36,885.00, according to ZipRecruiter salary data. Most workers in this role earn between $33,000.00 and $40,800.00 per year, depending on experience, location, and employer.

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What cities near Waterford, WI are hiring for Insurance Utilization Reviewer jobs?

Cities near Waterford, WI with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you

Registered Nurse Clinical Manager

CenterWell Primary Care

Racine, WI • On-site

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 7 days ago

CenterWell rating

9.0

Company rating: 9.0 out of 10

Based on 10 frontline employees who took The Breakroom Quiz

Job description

Become a part of our caring community
$10,000 SIGN ON BONUS!
Work Schedule: Full-time/40 Hours
Position Type: On-site
Branch Location: West Allis, WI
This is NOT a remote or work-from-home position. You will sit on-site at our West Allis, WI branch location.
As a Clinical Manager at CenterWell Home Health, reporting to the Branch Director, you will lead and support a team of dedicated clinicians who deliver compassionate, highquality care in the home setting. By guiding clinical practice, coordinating patient services, and ensuring excellence in every step of the care journey, you'll empower patients to achieve their highest level of independence while helping your team thrive in their roles.

As a Registered Nurse Clinical Manager, you will:

  • Oversee clinical operations for the location, including patient care delivery, staff management, documentation quality, and regulatory compliance, working onsite in-office.
  • Review referrals, determine admission appropriateness, assign clinicians, and ensure Plans of Care meet patient needs and agency standards.
  • Guide, support, and educate clinicians; help goalset, care planning, and clinical decisionmaking; and remain available during operating hours for clinical support.
  • Ensure clinical documentation, audits, and billing meet Medicare, payer, and company standards; monitor case management quality and outcomes.
  • Participate in hiring, training, performance evaluation, coaching, and corrective action for clinical staff.
  • Conduct ongoing staff education based on documentation review, utilization review findings, and performance improvement data.
  • Coordinate communication among physicians, team members, and caregivers to support care coordination, discharge planning, and outcome achievement.
  • Participate in quality improvement, data tracking, budgeting activities, marketing initiatives, and community relationship development.
  • Provide direct patient care on a limited basis in exceptional or unplanned circumstances and act as Branch Director in their absence.
  • Perform additional tasks to support clinical operations and organizational goals.

Use your skills to make an impact

Required Experience/Skills:

  • Graduate of an accredited School of Nursing.
  • Current state license as a Registered Nurse.
  • Proof of current CPR.
  • Valid driver's license, auto insurance and reliable transportation.
  • Two years as a Registered Nurse with at least one-year of management experience in a home care, hospice or equivalent environment.
  • Home health experience is required.
  • Management and people leadership experience, required.
  • OASIS experience, required.
  • Homecare Homebase (HCHB) experience, preferred.
  • CMS PDGM billing knowledge or experience, preferred.

Additional Information

  • Normal Hours of Operation: M-F / 8a-5p (CT)
  • On-Call: Required
  • Branch Size: 156 Census (4.5 STAR rating)
  • Annual Bonus: Eligible for the annual incentive bonus which has pay-outs both quarterly and annually.

Additional Information

TB Statement:

This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Driving Statement:

This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

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.


$77,200 - $106,200 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About Us
About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers - all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer atCenterWell.com.


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.

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