The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
RN Coordinator Utilization Management
Menasha, WI · On-site +1
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
RN Coordinator Utilization Management
Menasha, WI · On-site +1
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable ...
Locum Physician (MD/DO) - Family Practice in Oshkosh, WI
Oshkosh, WI · On-site
$155/hr
... nursing, mental health, administrative, and security teams * Participate in quality assurance, peer review, and performance improvement activities * Address clinical risk management, utilization ...
Locum Physician (MD/DO) - Family Practice in Oshkosh, WI
Oshkosh, WI · On-site
$155/hr
... nursing, mental health, administrative, and security teams * Participate in quality assurance, peer review, and performance improvement activities * Address clinical risk management, utilization ...
MDS Coordinator
Oshkosh, WI · On-site
$80K - $90K/yr
Run Utilization Review Meetings and ensure PDPM scores and rates are validated * Review and Educate ... Must hold an active LPN or RN license in the state of Wisconsin. * Strong knowledge of the MDS ...
Quick apply
MDS Coordinator
Oshkosh, WI · On-site
$80K - $90K/yr
Run Utilization Review Meetings and ensure PDPM scores and rates are validated * Review and Educate ... Must hold an active LPN or RN license in the state of Wisconsin. * Strong knowledge of the MDS ...
RN Care Manager
Menasha, WI · Remote
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
RN Care Manager
Menasha, WI · Remote
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
RN Care Manager
Menasha, WI · Remote
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
RN Care Manager
Menasha, WI · Remote
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...
Specialty Pharmacist
Green Bay, WI · On-site
$91K - $163K/yr
Explore opportunities with CPS , part of the Optum family of businesses. We're dedicated to ... Review and manage specialty medication therapies for complex, chronic, or high-cost conditions
Specialty Pharmacist
Green Bay, WI · On-site
$91K - $163K/yr
Explore opportunities with CPS , part of the Optum family of businesses. We're dedicated to ... Review and manage specialty medication therapies for complex, chronic, or high-cost conditions
... duties reviewing and accepting patients, verifies insurance, and assists with insurance pre ... Experience in the managed care pre-certification process, level of care assessments and utilization ...
... duties reviewing and accepting patients, verifies insurance, and assists with insurance pre ... Experience in the managed care pre-certification process, level of care assessments and utilization ...
Occupational Health Case Manager
Neenah, WI · On-site
$38.20 - $57.30/hr
Uses nursing assessment and clinical reasoning skills to assess patient's medical history, current ... utilization monitoring/review activities to the appropriate committees/persons. * Works closely ...
Occupational Health Case Manager
Neenah, WI · On-site
$38.20 - $57.30/hr
Uses nursing assessment and clinical reasoning skills to assess patient's medical history, current ... utilization monitoring/review activities to the appropriate committees/persons. * Works closely ...
Occupational Health Case Manager
Neenah, WI · On-site
$38.20 - $57.30/hr
Uses nursing assessment and clinical reasoning skills to assess patient's medical history, current ... utilization monitoring/review activities to the appropriate committees/persons. * Works closely ...
Occupational Health Case Manager
Neenah, WI · On-site
$38.20 - $57.30/hr
Uses nursing assessment and clinical reasoning skills to assess patient's medical history, current ... utilization monitoring/review activities to the appropriate committees/persons. * Works closely ...
... utilization of supplies or equipment and regular profits and loss review. * Responsible for all ... Graduate of an accredited School of Nursing (RN). * Current appropriate state licensure. EXPERIENCE ...
... utilization of supplies or equipment and regular profits and loss review. * Responsible for all ... Graduate of an accredited School of Nursing (RN). * Current appropriate state licensure. EXPERIENCE ...
... utilization of supplies or equipment and regular profits and loss review. * Responsible for all ... Graduate of an accredited School of Nursing (RN). * Current appropriate state licensure. EXPERIENCE ...
... utilization of supplies or equipment and regular profits and loss review. * Responsible for all ... Graduate of an accredited School of Nursing (RN). * Current appropriate state licensure. EXPERIENCE ...
Performs independent technical reviews, makes recommendations, and provides technical guidance as ... . Locations: Green Bay, WI, Madison, WI, Milwaukee, WI (East Wisconsin Avenue)
Performs independent technical reviews, makes recommendations, and provides technical guidance as ... . Locations: Green Bay, WI, Madison, WI, Milwaukee, WI (East Wisconsin Avenue)
Optum Utilization Review Nurse information
See Appleton, WI salary details
$20.88 - $25.10
2% of jobs
$25.10 - $29.32
9% of jobs
$32.21 is the 25th percentile. Wages below this are outliers.
$29.32 - $33.54
21% of jobs
The median wage is $36.96 / hr.
$33.54 - $37.76
23% of jobs
$37.76 - $41.98
13% of jobs
$45.27 is the 75th percentile. Wages above this are outliers.
$41.98 - $46.21
10% of jobs
$46.21 - $50.43
8% of jobs
$50.43 - $54.65
5% of jobs
$54.65 - $58.87
5% of jobs
$58.87 - $63.09
2% of jobs
$63.09 - $67.32
2% of jobs
$20
$41
$67
How much do optum utilization review nurse jobs pay per hour?
As of Sep 6, 2026, the average hourly pay for optum utilization review nurse in Appleton, WI is $41.26, according to ZipRecruiter salary data. Most workers in this role earn between $32.60 and $47.36 per hour, depending on experience, location, and employer.
What does an Optum Utilization Review Nurse do?
An Optum Utilization Review Nurse is responsible for reviewing medical records and patient cases to ensure that healthcare services provided are medically necessary and compliant with insurance guidelines. They evaluate treatment plans, collaborate with healthcare providers, and help determine coverage decisions for patients. By assessing the appropriateness of care, they help manage healthcare costs and improve patient outcomes. Their work involves communication with physicians, patients, and insurance representatives to ensure efficient and effective care delivery.
What are the key skills and qualifications needed to thrive as an Optum Utilization Review Nurse?
To thrive as an Optum Utilization Review Nurse, you need strong clinical assessment skills, a current RN license, and experience in case management or utilization review. Familiarity with clinical documentation systems, InterQual or Milliman Care Guidelines, and managed care regulations is typically required. Attention to detail, critical thinking, and effective communication are crucial soft skills for this role. These competencies are vital to ensure appropriate care decisions, regulatory compliance, and collaboration with interdisciplinary teams for optimal patient outcomes.
How does an Optum Utilization Review Nurse typically collaborate with physicians and other healthcare professionals during the review process?
As an Optum Utilization Review Nurse, you will frequently interact with physicians, case managers, and other healthcare providers to assess the medical necessity and appropriateness of patient care. This collaboration often involves reviewing clinical documentation, participating in multidisciplinary meetings, and communicating findings or recommendations to ensure quality and cost-effective care. Building strong professional relationships and maintaining clear, respectful communication are key to facilitating smooth care transitions and achieving optimal patient outcomes. This collaborative approach helps ensure that all parties are aligned with evidence-based guidelines and organizational policies.
What is the difference between Optum Utilization Review Nurse vs Optum Case Manager?
| Aspect | Optum Utilization Review Nurse | Optum Case Manager |
|---|---|---|
| Credentials | RN license, certifications in case management or utilization review often preferred | RN license, case management certification often preferred |
| Work Environment | Reviewing medical records, assessing insurance claims, working in healthcare or insurance settings | Coordinating patient care, managing cases, working in healthcare or insurance settings |
| Employer & Industry | Health insurance companies, healthcare providers, utilization review departments | Health insurance companies, healthcare organizations, patient advocacy |
Optum Utilization Review Nurses primarily evaluate medical necessity and approve or deny insurance claims, focusing on utilization review. In contrast, Optum Case Managers coordinate patient care, develop treatment plans, and support patient needs. Both roles require nursing credentials and work within healthcare or insurance environments, but their core responsibilities differ in focus and scope.
What are popular job titles related to Optum Utilization Review Nurse jobs in Appleton, WI?
For Optum Utilization Review Nurse jobs in Appleton, WI, the most frequently searched job titles are:
- Clinical Review Nurse Remote
- No Experience Utilization Review Nurse
- Remote Utilization Review Nurse
- Utilization Review Rn
- Night Utilization Review Nurse
- Flex Schedule Remote Utilization Review Nurse
- Freelance Utilization Review Nurse
- Remote Utilization Review Social Worker
- Temporary Utilization Review Nurse
- Remote Utilization Review Rn
What job categories do people searching Optum Utilization Review Nurse jobs in Appleton, WI look for?
The top searched job categories for Optum Utilization Review Nurse jobs in Appleton, WI are:
What cities near Appleton, WI are hiring for Optum Utilization Review Nurse jobs?
Cities near Appleton, WI with the most Optum Utilization Review Nurse job openings:
Full-time
Re-posted 3 days ago
Network Health rating
7.9
Based on 5 frontline employees who took The Breakroom Quiz
187th of 315 rated insurance
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 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
About Network Health
Sourced by ZipRecruiter
Industry
Insurance services
Company size
201 - 500 Employees
Headquarters location
Menasha, WI, US
Year founded
1982