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Remote Utilization Review Manager Jobs in Appleton, WI

Network Health, Inc

Pharmacist

Menasha, WI · On-site +1

This may include Case Management, Disease Management, Medication Therapy Management, Drug Utilization Review and creation of Clinical Programs to outcomes and cost effective drug therapy. This role ...

Network Health

Pharmacist

Menasha, WI · On-site +1

This may include Case Management, Disease Management, Medication Therapy Management, Drug Utilization Review and creation of Clinical Programs to outcomes and cost effective drug therapy. This role ...

Network Health

Associate Medical Director

Menasha, WI · On-site +1

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 ...

Wisconsin

Facilities Coordinator

Oshkosh, WI · On-site +1

$65K/yr

The Facilities Coordinator supports the effective planning, management, and utilization of ... The position reviews space requests, develops test fits and facility options, evaluates potential ...

A.O. Smith

Regional Sales Manager

Appleton, WI · Remote

Take part in planning sessions to gauge progress, overcome challenges and review opportunities ... Proven ability to manage time and workload from a remote/home based office We Offer Competitive ...

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All JobsUtilization Review JobsRemote Utilization Review Manager JobsRemote Utilization Review Manager Jobs in Appleton, WI

Remote Utilization Review Manager information

See Appleton, WI salary details

$38.1K

$88.8K

$163.4K

How much do remote utilization review manager jobs pay per year?

As of Sep 9, 2026, the average yearly pay for remote utilization review manager in Appleton, WI is $88,802.00, according to ZipRecruiter salary data. Most workers in this role earn between $58,100.00 and $106,800.00 per year, depending on experience, location, and employer.

What is a remote utilization review manager?

A Remote Utilization Review Manager is a healthcare professional responsible for overseeing the review of medical services and determining the necessity, appropriateness, and efficiency of those services from a remote location. They ensure that healthcare providers comply with guidelines and that patients receive appropriate care without unnecessary procedures. These managers work with clinical teams, insurance companies, and regulatory agencies to optimize patient outcomes and manage healthcare costs. Working remotely allows them to perform these duties using digital health records and telecommunication tools.

What are the key skills and qualifications needed to thrive as a remote utilization review manager?

To thrive as a Remote Utilization Review Manager, you need expertise in healthcare management, case review, and regulatory compliance, typically supported by a nursing degree (RN or BSN) and relevant certifications such as CCM or URAC. Familiarity with utilization management software, electronic health records (EHRs), and payer systems is essential. Strong analytical thinking, attention to detail, and excellent communication skills help navigate complex cases and collaborate with clinical teams and insurers. These skills ensure effective resource utilization, regulatory adherence, and optimal patient outcomes in a remote healthcare environment.

What are some common challenges faced by a remote utilization review manager, and how can they be addressed?

A Remote Utilization Review Manager often encounters challenges such as maintaining effective communication with clinical teams, ensuring timely and accurate reviews, and staying updated with changing regulations and payer requirements. To address these, it's important to leverage secure collaborative platforms, establish clear workflows, and participate in ongoing training. Building strong relationships with team members and regularly reviewing protocols also help in overcoming remote work hurdles and ensuring compliance and efficiency.

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

AspectRemote Utilization Review ManagerRemote Utilization Review Nurse
CredentialsTypically requires a nursing license, certifications like URAC or AAPC, and management experienceLicensed Registered Nurse (RN) with utilization review certification often preferred
Work EnvironmentOversees review teams, manages processes, and ensures compliance remotelyPerforms case reviews, assesses medical necessity, and documents findings remotely
Employer & Industry UsageHealth insurance companies, third-party administrators, healthcare organizations

The Remote Utilization Review Manager focuses on overseeing review teams and managing processes, while the Remote Utilization Review Nurse conducts case assessments and medical necessity reviews. Both roles require nursing credentials and are integral to healthcare utilization management, but differ in responsibilities and leadership levels.

What are popular job titles related to Remote Utilization Review Manager jobs in Appleton, WI?

For Remote Utilization Review Manager jobs in Appleton, WI, the most frequently searched job titles are:

What job categories do people searching Remote Utilization Review Manager jobs in Appleton, WI look for?

The top searched job categories for Remote Utilization Review Manager jobs in Appleton, WI are:

What cities near Appleton, WI are hiring for Remote Utilization Review Manager jobs?

Cities near Appleton, WI with the most Remote Utilization Review Manager job openings:

Remote Utilization Review Manager jobs near you

RN Coordinator Utilization Management

Menasha, WI • On-site, Remote

Network Health WI
Insurance Services • 201 - 500 employees
Learn more about Network Health WIexternal

Full-time

Re-posted 4 days ago

Network Health rating

7.9

Company rating: 7.9 out of 10

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
Equal Opportunity Employer
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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