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Remote Utilization Review Jobs in Madison, WI (NOW HIRING)

WPS

Pharmacy Vendor Coordinator

Madison, WI · On-site +1

$19 - $24.75/hr

Interpret pharmacy claims and utilization data, evaluate trends, and determine appropriate actions ... Please review Remote Worker FAQs for additional information. Benefits * Remote and hybrid work ...

New

WPS Health Solutions

Pharmacy Vendor Coordinator

Madison, WI · On-site +1

$19 - $24.75/hr

Interpret pharmacy claims and utilization data, evaluate trends, and determine appropriate actions ... Please review Remote Worker FAQs for additional information. Benefits * Remote and hybrid work ...

New

WPS

Senior IT Security Analyst

Madison, WI · On-site +1

$90K - $115K/yr

... utilization. * Have developed security awareness training programs to educate employees on ... Please review Remote Worker FAQs for additional information. Benefits * Remote and hybrid work ...

Agrace

Benefit & Compensation Analyst (on site)

Madison, WI · Remote

$70K - $87K/yr

Madison, WI Full Time | Day | Monday-Friday | 8am-5pm (option for 1 Day/Week remote) Make a lasting ... This role analyzes market trends, internal data, employee feedback, and program utilization to ...

SHINE Technologies LLC

Licensing Manager

Janesville, WI · On-site +1

$160K - $200K/yr

Hybrid or remote work arrangement will be considered. While our headquarters is located in ... Interface with regulatory agencies in the planning of regulatory engagements, regulatory reviews ...

SHINE Technologies LLC

Licensing Engineer

Janesville, WI · On-site +1

$73K - $121K/yr

... support of the review of licensing actions by the U.S. Nuclear Regulatory Commission; the ... Hybrid or remote work arrangement will be considered. While our headquarters is located in ...

Quartz

RN Complex Care Specialist

Madison, WI · Remote

$72K - $90K/yr

Proficiency using Epic systems and remote monitoring programs. * Cultural competence and sensitivity to work with individuals from varied backgrounds. * Case Management (CCM) certification preferred ...

All JobsUtilization Review JobsRemote Utilization Review JobsRemote Utilization Review Jobs in Madison, WI

Remote Utilization Review information

See Madison, WI salary details

$21

$42

$69

How much do remote utilization review jobs pay per hour?

As of Sep 6, 2026, the average hourly pay for remote utilization review in Madison, WI is $42.60, according to ZipRecruiter salary data. Most workers in this role earn between $33.65 and $48.94 per hour, depending on experience, location, and employer.

What is a remote utilization review?

A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.

What does a remote utilization review do?

A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.

What are the key skills and qualifications needed to thrive in remote utilization review?

To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.

What are the most commonly searched types of Utilization Review jobs in Madison, WI?

The most popular types of Utilization Review jobs in Madison, WI are:

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

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

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

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

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

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

Remote Utilization Review jobs near you
Infographic showing various Remote Utilization Review job openings in Madison, WI as of August 2026, with employment types broken down into 1% As Needed, 77% Full Time, 17% Part Time, 2% Temporary, 2% Contract, and 1% Nights. Highlights an 86% Physical, 2% Hybrid, and 12% Remote job distribution, with an average salary of $88,617 per year, or $42.6 per hour.

Pharmacy Vendor Coordinator

WPS

Madison, WI • On-site, Remote

$19 - $24.75/hr

Full-time

Medical, Dental, Retirement, PTO

Posted 3 days ago

New

Job description

Role Snapshot
The Pharmacy Coordinator will oversee development and execution of audit processes that monitor delegated activities performed by the Pharmacy Benefits Manager (PBM). The role will build working expertise in the PBM's online claims system and its capabilities, serving as a knowledgeable resource for the Health Services Contract Center and other internal teams to determine appropriate actions to resolve escalated customer issues.
Salary Range
75-78k, pay may fluctuate based on experience.
Work Location
Employees within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) will be expected to be able to be able to work Hybrid 2 days a week on a regular basis.
We 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 enjoy the following:
  • Serve as the primary subject-matter expert for internal teams on pharmacy benefits and system capabilities, exercising independent judgment to guide internal teams and resolve highly complex or escalated customer issues.
  • Interpret pharmacy claims and utilization data, evaluate trends, and determine appropriate actions to address emerging issues or performance gaps.
  • Make decisions regarding PBM operational needs, partnering with PBM to maintain performance-monitoring processes, resolve discrepancies and manage escalating vendor concerns.
  • Collaborate with Call Center, Sales, Account Management, Marketing, and Health Services to enhance organizational, determining the most effective educational materials
  • Coordinate PBM employer group reporting and support external customer discussions, interpreting pharmacy trends and benefit design to provide clear guidance and recommendations.
  • Work with Risk Management to evaluate high-cost claims and determine actions for Short Term Health Plan denials.
  • Assist Plan Product and related departments with mask configuration and system research, exercising judgment when deciding how to partner with the PBM on benefit or system updates.
  • Coordinate with PBM and pharmacy vendors to gather and review materials for presentations to Quality Improvement Committee (QIC), including analyses of program performance, pharmacy policies, vendor performance, and audit requirements.
  • Quantify savings and outcomes for pharmacy programs, evaluating results and determining opportunities for process improvements or cost reductions.
  • Other duties as assigned

Minimum Qualifications
  • High school diploma and work-related experience.
  • 5 or more years in a Pharmacy Benefit role, working for a Health Insurer, Pharmacy Benefit Manager, or equivalent
  • Knowledge of health benefits insurance carrier concepts, pharmacy benefit management operations, terminology, and relevant regulatory standards (URAC, CMS, state).
  • Understanding of pharmacy claims processing, formulary management, and basic utilization review workflows.
  • Excellent communication and strong relationship management skills with internal and external partners.
  • Strong analytical and problem-solving skills,
  • Strong attention to detail skills, and ability to manage multiple priorities.

Preferred Qualifications
  • Associate's degree in business, healthcare, or related field,

Remote Work Requirements
  • High speed cable or fiber internet.
  • 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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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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