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Remote Behavioral Health Utilization Review Jobs in Sun Prairie, WI

WPS

Appeals Registered Nurse

Madison, WI · On-site +1

$30.50 - $40.25/hr

Please review Remote Worker FAQs for additional information. Benefits * Remote and hybrid work ... Health insurance, dental insurance, and telehealth services start DAY 1 * Professional and ...

Urrly

Telehealth Nurse Practitioner (Remote)

Madison, WI · Remote

$600 - $720/hr

Conduct Comprehensive Health Assessments via telehealth * Document risk adjustment (HCC coding ... Review medical history, medications, and preventive needs * Document visits using ICD-10 and CPT II ...

MDS Solutions

REMOTE MDS Coordinator

Madison, WI · Remote

$34.50 - $44/hr

Comprehensive health and life insurance. * 401K with discretionary match * Mileage and licensure ... Review and verify MDS documentation and charting requirements to support the clinical services ...

MDS Solutions

REMOTE MDS Coordinator

Madison, WI · On-site +1

$34.50 - $44/hr

Comprehensive health and life insurance. * 401K with discretionary match * Mileage and licensure ... Review and verify MDS documentation and charting requirements to support the clinical services ...

MDS Solutions

REMOTE MDS Coordinator

Madison, WI · On-site +1

$34.50 - $44/hr

Comprehensive health and life insurance. * 401K with discretionary match * Mileage and licensure ... Review and verify MDS documentation and charting requirements to support the clinical services ...

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Remote Behavioral Health Utilization Review information

See Sun Prairie, WI salary details

$20

$41

$67

How much do remote behavioral health utilization review jobs pay per hour?

As of Aug 21, 2026, the average hourly pay for remote behavioral health utilization review in Sun Prairie, WI is $41.14, according to ZipRecruiter salary data. Most workers in this role earn between $32.50 and $47.26 per hour, depending on experience, location, and employer.

What is a remote behavioral health utilization review?

A Remote Behavioral Health Utilization Review job involves evaluating behavioral health treatment plans and services to ensure they meet insurance guidelines, medical necessity, and regulatory requirements. Professionals in this role review clinical documentation, assess patient needs, and collaborate with healthcare providers to determine appropriate levels of care. They work remotely, often for insurance companies or healthcare organizations, to authorize or deny coverage based on established criteria. Strong clinical knowledge, attention to detail, and communication skills are essential for success in this role.

What are the typical daily responsibilities for someone working in remote behavioral health utilization review?

In a Remote Behavioral Health Utilization Review role, your daily tasks often include reviewing clinical documentation, assessing medical necessity for behavioral health services, and making authorization or denial recommendations according to established guidelines. You’ll frequently interact with providers, case managers, and insurance representatives to gather information and clarify care requests. Additionally, your day may involve documenting decisions, participating in case review meetings, and staying updated on evolving policies. Working remotely, you'll communicate primarily via secure electronic systems, phone, and video conferencing. This structure typically offers flexibility but also requires strong self-motivation and organization.

What are the key skills and qualifications needed to thrive in remote behavioral health utilization review, and why are they important?

To excel in Remote Behavioral Health Utilization Review, candidates generally need a clinical background such as a nursing or social work license, strong analytical skills, and experience with behavioral health diagnoses and treatment planning. Familiarity with utilization management software, electronic health records (EHRs), and insurance coding systems is often required, along with certifications like CCM (Certified Case Manager) or URAC accreditation being valued. Excellent communication, critical thinking, and organizational skills help professionals handle complex cases and collaborate effectively in a virtual team environment. These competencies ensure accurate review of mental health services, compliance with payer requirements, and optimal patient outcomes.

What cities near Sun Prairie, WI are hiring for Remote Behavioral Health Utilization Review jobs?

Cities near Sun Prairie, WI with the most Remote Behavioral Health Utilization Review job openings:

Remote Behavioral Health Utilization Review jobs near you
Infographic showing various Remote Behavioral Health Utilization Review job openings in Sun Prairie, WI as of June 2026, with employment types broken down into 97% Full Time, 2% Part Time, and 1% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $85,567 per year, or $41.1 per hour.

Appeals Registered Nurse

WPS

Madison, WI • On-site, Remote

$30.50 - $40.25/hr

Full-time

Medical, Dental, Retirement, PTO

Posted 11 days ago

Job description

Role SnapshotThe Appeals Nurse examines medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines in accordance with Medicare regulations and policies. The Appeals RN works in collaboration with the Appeals Examiners/Reps to ensure redeterminations are medically reviewed as needed and completed timely.
Salary Range
66-68k
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
Work LocationWe are open to remote work in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin
How do I know this opportunity is right for me? If you are interested in the following activities:
  • Review and assess first-level appeal cases for denied services, ensuring all relevant medical documentation, coding, and clinical information are provided to support the appeal.
  • Conduct comprehensive medical record reviews to determine the clinical necessity of services and make recommendations for resolution based on clinical guidelines, policy, and the medical necessity of care.
  • Prepare and submit written appeal letters, including comprehensive rationales and supporting clinical evidence.
  • Ensure timely follow-up on all appeals and ensure proper resolution is reached in accordance with company policies and external regulations.
  • Maintain awareness of healthcare laws, regulations, and policies relevant to the appeals process, ensuring all actions comply with regulatory and contractual requirements.
  • Work with and provide directions to Redetermination Representatives to ensure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.

Minimum Qualifications
  • Associate's (ASN) or Bachelor's Degree in Nursing (BSN).
  • Active RN license, applicable to state of practice in good standing.
  • One (1) or more years of clinical experience in a healthcare setting (hospital/bedside, case management, MDS/Skilled Nursing, etc.).
  • Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
  • Strong attention to detail and organizational skills to manage multiple cases simultaneously.
  • Basic knowledge and understanding of medical/clinical review processes (i.e., Appeals/Utilization Review).
  • Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.

Preferred Qualifications
  • Experience working for a Medicare Administrative Contractor (MAC) preferred.
  • One (1) or more years of experience working in Medical Management (e.g., MDS role), Medical Review, Utilization Management/Review, or Appeals preferred.
  • Basic Medicare knowledge and/or experience preferred.

Remote Work Requirements
  • Wired (ethernet cable) internet connection from your router to your computer.
  • High speed cable or fiber
  • Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
  • Please review Remote Worker FAQs for additional information.

Benefits
  • Remote and hybrid work options available
  • Performance bonus and/or merit increase opportunities
  • 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
  • Competitive paid time off
  • Health insurance, dental insurance, and telehealth services start DAY 1
  • Professional and Leadership Development Programs
  • Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are
WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
Culture Drives Our Success
WPS' culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.
We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
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Medicare (GHA)
This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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