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 ...
RN Care Manager
Menasha, WI · Remote
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
RN Care Manager
Menasha, WI · Remote
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
RN Care Manager
Menasha, WI · Remote
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
RN Care Manager
Menasha, WI · Remote
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
RN Care Manager
Menasha, WI · On-site +1
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
RN Care Manager
Menasha, WI · On-site +1
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
... and care as delegated by the manager * Represent Utilization Management at interdepartmental meetings and committees * Establish and Maintain Positive Relationships with Internal and External ...
... and care as delegated by the manager * Represent Utilization Management at interdepartmental meetings and committees * Establish and Maintain Positive Relationships with Internal and External ...
RN Care Manager
Menasha, WI · On-site
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
RN Care Manager
Menasha, WI · On-site
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
... and care as delegated by the manager * Represent Utilization Management at interdepartmental meetings and committees * Establish and Maintain Positive Relationships with Internal and External ...
... and care as delegated by the manager * Represent Utilization Management at interdepartmental meetings and committees * Establish and Maintain Positive Relationships with Internal and External ...
Clinical Initiatives Business Analyst
Madison, WI · On-site
$78K - $134K/yr
The ideal candidate is skilled in healthcare data analysis, experienced with clinical measures (utilization and care management, managed care performance metrics and quality data,), and comfortable ...
Clinical Initiatives Business Analyst
Madison, WI · On-site
$78K - $134K/yr
The ideal candidate is skilled in healthcare data analysis, experienced with clinical measures (utilization and care management, managed care performance metrics and quality data,), and comfortable ...
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 ...
Description The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews ...
Description The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews ...
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 ...
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
New
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
New
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
New
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer
New
Registered Nurse - Care Manager- Adult Cardiology- St Mary's Medical Office Building
Green Bay, WI · On-site
... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ... Coordinates comprehensive care management activities across the continuum, including pre-visit ...
Registered Nurse - Care Manager- Adult Cardiology- St Mary's Medical Office Building
Green Bay, WI · On-site
... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ... Coordinates comprehensive care management activities across the continuum, including pre-visit ...
... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ... Coordinates comprehensive care management activities across the continuum, including pre-visit ...
... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ... Coordinates comprehensive care management activities across the continuum, including pre-visit ...
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
New
Previous experience in case management, utilization management, insurance, or managed care preferred * Experience with Medicare, Medicaid preferred Network Health is an Equal Opportunity Employer ...
New
Registered Nurse Care Manager- Luxemburg, Kewaunee, Manitowoc - Luxemburg, WI
Luxemburg, WI · On-site
Back Registered Nurse Care Manager- Luxemburg, Kewaunee, Manitowoc #26-416 Luxemburg, Wisconsin ... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ...
Registered Nurse Care Manager- Luxemburg, Kewaunee, Manitowoc - Luxemburg, WI
Luxemburg, WI · On-site
Back Registered Nurse Care Manager- Luxemburg, Kewaunee, Manitowoc #26-416 Luxemburg, Wisconsin ... utilization, and high-quality, patient-centered care. This role implements evidence-based clinical ...
Utilization Care Manager information
How does a utilization care manager collaborate with medical and administrative teams to ensure effective patient care?
Utilization Care Managers work closely with physicians, nursing staff, and administrative teams to review patient cases, determine medical necessity, and coordinate appropriate care plans. They frequently participate in interdisciplinary meetings, communicate with insurance providers regarding authorizations, and ensure compliance with regulatory guidelines. This collaborative approach helps to optimize resource utilization, improve patient outcomes, and support smooth transitions of care. Being proactive in communication and documentation is key to success in this role.
What is a utilization care manager?
Utilization Care Managers are healthcare professionals responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They work to ensure that patients receive the right care at the right time, while also helping healthcare organizations manage costs and comply with regulations. Utilization Care Managers often review patient cases, coordinate with medical staff, and interact with insurance companies to authorize or deny services. Their goal is to optimize healthcare delivery, reduce unnecessary procedures, and improve patient outcomes.
What are the key skills and qualifications needed to thrive as a utilization care manager, and why are they important?
To thrive as a Utilization Care Manager, you need a background in healthcare, typically as a registered nurse or social worker, with expertise in care coordination and utilization review. Familiarity with utilization management software, medical necessity guidelines (such as Milliman or InterQual), and knowledge of insurance regulations are important. Strong analytical thinking, attention to detail, and effective communication skills help you advocate for patients while working with healthcare teams and payers. These skills ensure appropriate resource use, quality patient outcomes, and compliance with regulatory standards.
What is the difference between Utilization Care Manager vs Utilization Review Nurse?
| Aspect | Utilization Care Manager | Utilization Review Nurse |
|---|---|---|
| Credentials | RN, case management certification | RN, certification in utilization review |
| Work Environment | Healthcare facilities, insurance companies | Hospitals, insurance companies, outpatient clinics |
| Primary Focus | Coordinating patient care, managing resources | Reviewing medical necessity, approving treatments |
Utilization Care Managers focus on coordinating patient care and managing resources, while Utilization Review Nurses primarily evaluate medical necessity for treatments. Both roles require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.
What are popular job titles related to Utilization Care Manager jobs in Wisconsin? For Utilization Care Manager jobs in Wisconsin, the most frequently searched job titles are:
What job categories do people searching Utilization Care Manager jobs in Wisconsin look for? The top searched job categories for Utilization Care Manager jobs in Wisconsin are:
- Remote Occupational Therapy Utilization Review
- Volunteer Aetna Utilization Review Nurse
- Dental Utilization Review
- Manager Facility Services
- Continuum Of Care
- Internship Remote Utilization Review
- Insurance Utilization Reviewer
- Senior Specialist Cigna Utilization Review
- Utilization Review Coordinator
- Integrated Healthcare
What cities in Wisconsin are hiring for Utilization Care Manager jobs? Cities in Wisconsin with the most Utilization Care Manager job openings:
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.Â
Location:Â 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:Â 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