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Senior Rn Utilization Review Nurse Jobs in Appleton, WI

American Traveler

Travel RN Case Manager

Appleton, WI · On-site

Travel RN - Case Management/Utilization Review - Case Management About American Traveler With over 25 years of experience, American Traveler has established a reputation for outstanding customer ...

Eden Senior Care

Registered Nurse (RN)

Omro, WI · On-site

$40 - $45/hr

Eden Senior Care , founded in 2016, is a growing Healthcare Management company, focused on managing ... We are recruiting positive, reliable Full-Time Nurses (RN or LPN) to join our team on AM and PM ...

Eden Senior Care

Registered Nurse (RN)

Omro, WI · On-site

$40 - $45/hr

Eden Senior Care , founded in 2016, is a growing Healthcare Management company, focused on managing ... We are recruiting positive, reliable Full-Time Nurses (RN or LPN) to join our team on AM and PM ...

New Perspective

Registered Nurse RN

Oneida, WI · On-site

Why New Perspective Senior Living? A career with a purpose starts here! This is an exciting time to ... For further information, please review the Know Your Rights notice from the Department of Labor.

Eden Senior Care

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 ...

TEEMA Group

Registered Nurse (RN)

Oshkosh, WI · On-site

$55 - $60/hr

Registered Nurse (RN)Role Summary Are you a resilient, highly analytical Registered Nurse looking ... Prior professional experience navigating behavioral health, substance utilization programs, or ...

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Senior Rn Utilization Review Nurse information

See Appleton, WI salary details

$20

$41

$67

How much do senior rn utilization review nurse jobs pay per hour?

As of Jul 17, 2026, the average hourly pay for senior rn 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 is the difference between Senior Rn Utilization Review Nurse vs Rn Case Manager?

AspectSenior Rn Utilization Review NurseRn Case Manager
CertificationsRN license, possibly UR or case management certificationRN license, often case management certification
Work EnvironmentHospitals, insurance companies, healthcare organizationsHospitals, community health, insurance providers
Primary FocusReviewing medical necessity and utilization of servicesCoordinating patient care and discharge planning
Common UsageUsed in insurance and healthcare review settingsUsed in patient care coordination and discharge planning

The Senior Rn Utilization Review Nurse primarily focuses on evaluating the necessity and appropriateness of healthcare services, often working within insurance companies or healthcare organizations. In contrast, Rn Case Managers concentrate on coordinating patient care, discharge planning, and ensuring smooth healthcare delivery. Both roles require RN licensure and relevant certifications, but their daily responsibilities and work environments differ slightly.

Can I make $500,000 as a nurse?

Senior Rn Utilization Review Nurses typically earn salaries ranging from $80,000 to $120,000 annually, depending on experience, location, and employer. Earning $500,000 is uncommon in this role and usually requires additional responsibilities, bonuses, or working in high-paying regions or specialized settings.

What does a Senior RN Utilization Review Nurse do?

A Senior RN Utilization Review Nurse is a registered nurse who evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, apply clinical guidelines, and collaborate with healthcare providers to ensure that treatments are cost-effective and meet established standards of care. Additionally, they often mentor junior staff, participate in policy development, and help optimize resource utilization within healthcare organizations. Their work supports quality patient care while managing healthcare costs.

How to make 150,000 as a nurse?

Senior Rn Utilization Review Nurses can earn $150,000 by gaining extensive experience, obtaining advanced certifications such as CCM or ANCC, and working in high-paying settings like hospitals or insurance companies. Increasing responsibilities, working overtime, or taking on leadership roles can also boost income in this field.

What are some typical challenges faced by Senior RN Utilization Review Nurses when coordinating with multidisciplinary teams?

Senior RN Utilization Review Nurses often collaborate with physicians, case managers, and insurance representatives to ensure patients receive appropriate, cost-effective care. A common challenge is balancing clinical guidelines with payer requirements, which can sometimes lead to differing opinions on the necessity of certain treatments or services. Effective communication, strong negotiation skills, and up-to-date knowledge of regulatory standards are essential to navigate these situations successfully. Being proactive and maintaining strong professional relationships helps facilitate smoother approvals and promotes patient-centered care.

What are the key skills and qualifications needed to thrive as a Senior RN Utilization Review Nurse, and why are they important?

To thrive as a Senior RN Utilization Review Nurse, you need a strong clinical nursing background, active RN licensure, and in-depth knowledge of medical necessity criteria and healthcare regulations. Familiarity with utilization review software, electronic health records (EHRs), and certifications like CCM (Certified Case Manager) or URAC are highly beneficial. Exceptional critical thinking, attention to detail, and effective communication skills distinguish top performers in this role. These skills ensure accurate case evaluations, compliance with regulations, and optimized patient care while controlling healthcare costs.

How to make $200,000 a year as a nurse?

Senior Rn Utilization Review Nurses can reach a $200,000 annual salary by gaining extensive experience, obtaining advanced certifications, and working in high-paying settings such as insurance companies or specialty healthcare organizations. Developing expertise in case management, health policy, and utilizing clinical judgment can also increase earning potential, often supplemented by overtime or leadership roles.

How to get into utilization review as a nurse?

To become a utilization review nurse, typically a registered nurse (RN) must have clinical experience and obtain knowledge of insurance policies and healthcare regulations. Certification in case management or utilization review, such as the Certified Case Manager (CCM) credential, can enhance job prospects. Strong analytical skills, attention to detail, and familiarity with electronic health records (EHR) systems are also important for this role.
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Senior Rn Utilization Review Nurse jobs near you
RN Coordinator Utilization Management

RN Coordinator Utilization Management

Network Health, Inc

Menasha, WI

Full-time

Re-posted 12 days ago

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

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