A clinical background, particularly as an RN , along with utilization management and claims is ... Strong analytical and problem-solving skills with the ability to interpret complex data sets.
A clinical background, particularly as an RN , along with utilization management and claims is ... Strong analytical and problem-solving skills with the ability to interpret complex data sets.
Underpinned by technology, data, analytics, AI, change management, talent and sustainability ... As aNetwork Performance/Utilization Manager, your primary responsibilitiesmay include: * Advise ...
Underpinned by technology, data, analytics, AI, change management, talent and sustainability ... As aNetwork Performance/Utilization Manager, your primary responsibilitiesmay include: * Advise ...
$155K - $175K/yr
Analytics Team - Collaborate on drug trends and utilization data to inform clinical policy decisions, medical policy and formulary compliance, drug share shift and utilization management strategies
$155K - $175K/yr
Analytics Team - Collaborate on drug trends and utilization data to inform clinical policy decisions, medical policy and formulary compliance, drug share shift and utilization management strategies
... resource utilization, information management, revenue enhancement, and implement business ... clinical program operations; serving as a consultant to leadership on business intelligence ...
... resource utilization, information management, revenue enhancement, and implement business ... clinical program operations; serving as a consultant to leadership on business intelligence ...
Region Director Care Coordination-Central Region
South Milwaukee, WI · Remote
$69.41 - $103.25/hr
You will also require knowledge of utilization management processes and denial prevention ... Oversees clinical care management operations including progression of care, discharge planning, and ...
Region Director Care Coordination-Central Region
South Milwaukee, WI · Remote
$69.41 - $103.25/hr
You will also require knowledge of utilization management processes and denial prevention ... Oversees clinical care management operations including progression of care, discharge planning, and ...
Management Analyst
Madison, WI · On-site +1
$89K - $116K/yr
... resource utilization, information management, revenue enhancement, and implement business ... clinical program; experience planning, organizing, and developing studies or projects, making ...
Management Analyst
Madison, WI · On-site +1
$89K - $116K/yr
... resource utilization, information management, revenue enhancement, and implement business ... clinical program; experience planning, organizing, and developing studies or projects, making ...
Become a part of our caring community The Compliance Nurse 2 reviews utilization management ... Clinical experience working QIO appeals,expeditedrequest reviews and/or compliance * Health Plan ...
Become a part of our caring community The Compliance Nurse 2 reviews utilization management ... Clinical experience working QIO appeals,expeditedrequest reviews and/or compliance * Health Plan ...
Case Mgmt Care Coord Assoc
Milwaukee, WI · On-site
Provides initial ongoing assessment of the patient's clinical situation and inclusive of their ... Cross trained in the functions of the case management assistant and utilization management ...
Case Mgmt Care Coord Assoc
Milwaukee, WI · On-site
Provides initial ongoing assessment of the patient's clinical situation and inclusive of their ... Cross trained in the functions of the case management assistant and utilization management ...
The role involves providing support and consultation for utilization management (medical and ... Provide clinical support as needed to staff throughout Aspirus Inc.: e.g., complex case management ...
The role involves providing support and consultation for utilization management (medical and ... Provide clinical support as needed to staff throughout Aspirus Inc.: e.g., complex case management ...
Registered Nurse
Milwaukee, WI · On-site
... on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various ...
Registered Nurse
Milwaukee, WI · On-site
... on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various ...
... resource utilization, information management, revenue enhancement, and implement business ... clinical program; experience planning, organizing, and developing studies or projects, making ...
... resource utilization, information management, revenue enhancement, and implement business ... clinical program; experience planning, organizing, and developing studies or projects, making ...
Field Medical Director, Vascular Surgeon
Madison, WI · On-site
$130 - $140/hr
As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical ...
Field Medical Director, Vascular Surgeon
Madison, WI · On-site
$130 - $140/hr
As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical ...
Finance Manager, Clinical FP&A
Madison, WI · On-site
$88K - $152K/yr
... resource utilization. * Assess the financial impact of new clinical programs, services, and ... Maintain strong financial controls and risk management practices. * Assist in implementing and ...
Finance Manager, Clinical FP&A
Madison, WI · On-site
$88K - $152K/yr
... resource utilization. * Assess the financial impact of new clinical programs, services, and ... Maintain strong financial controls and risk management practices. * Assist in implementing and ...
Finance Manager, Clinical FP&A
Madison, WI · On-site
$88K - $152K/yr
... resource utilization. * Assess the financial impact of new clinical programs, services, and ... Maintain strong financial controls and risk management practices. * Assist in implementing and ...
Finance Manager, Clinical FP&A
Madison, WI · On-site
$88K - $152K/yr
... resource utilization. * Assess the financial impact of new clinical programs, services, and ... Maintain strong financial controls and risk management practices. * Assist in implementing and ...
As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical ...
As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical ...
... utilization management to minimize denials and appeals. * Leads care transition processes for clinical quality, cost-improvement initiatives, and maintains top decile performance for re ...
... utilization management to minimize denials and appeals. * Leads care transition processes for clinical quality, cost-improvement initiatives, and maintains top decile performance for re ...
Health Information Management Intern
Kenosha, WI · On-site
$14.50 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Health Information Management Intern
Kenosha, WI · On-site
$14.50 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Health Information Management Intern
$14.75 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Health Information Management Intern
$14.75 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Health Information Management Intern
Kenosha, WI · On-site
$14.75 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Health Information Management Intern
Kenosha, WI · On-site
$14.75 - $19.50/hr
... analytical thinker, possess strong oral and written communication skills, and be self-driven. If ... clinical experience at an acute care hospital, be RHIT eligible, have knowledge of medical ...
Ability to analyze financial data and generate logical strategies and plans based on analysis ... Project Management: Serves as customer liaison on project implementation and coordinates with ...
Ability to analyze financial data and generate logical strategies and plans based on analysis ... Project Management: Serves as customer liaison on project implementation and coordinates with ...
Utilization Management Clinical Analyst information
How does a utilization management clinical analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?
A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.
What are the key skills and qualifications needed to thrive as a utilization management clinical analyst?
To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.
What does a utilization management clinical analyst do?
A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.
What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?
| Aspect | Utilization Management Clinical Analyst | Utilization Review Nurse |
|---|---|---|
| Credentials | Healthcare degree, certifications like CCM or CUC | Registered Nurse (RN), state licensure, certifications like CCM |
| Work Environment | Insurance companies, healthcare organizations, utilization review departments | Hospitals, insurance companies, outpatient facilities |
| Employer & Industry | Health insurance providers, managed care organizations | Hospitals, insurance companies, healthcare facilities |
| Common Search & Comparison | Utilization Management Clinical Analyst vs Utilization Review Nurse |
The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.
What are popular job titles related to Utilization Management Clinical Analyst jobs in Wisconsin?
For Utilization Management Clinical Analyst jobs in Wisconsin, the most frequently searched job titles are:
- Therapist Utilization Review Remote
- Utilization Review Nurse
- No Experience Utilization Review Nurse
- Remote Behavioral Health Utilization Review
- Remote Utilization Management
- Utilization Review Physician
- Remote Utilization Management Pharmacist
- Manager Care Management
- Utilization Management Nurse
- Ltss Care Manager
What job categories do people searching Utilization Management Clinical Analyst jobs in Wisconsin look for?
The top searched job categories for Utilization Management Clinical Analyst jobs in Wisconsin are:
- Remote Aetna Utilization Review
- Volunteer Aetna Utilization Review Nurse
- Medical Recruitment Strategies
- Freelance International Utilization Review Nurse
- Manager Facility Services
- Molina Rn
- Internship Remote Utilization Review
- Utilization Review Case Manager
- Health Care Project Manager
- Insurance Utilization Review
What cities in Wisconsin are hiring for Utilization Management Clinical Analyst jobs?
Cities in Wisconsin with the most Utilization Management Clinical Analyst job openings:
Full-time
Medical, Retirement
Re-posted 15 hours ago
Aspirus Health rating
6.5
Based on 259 frontline employees who took The Breakroom Quiz
605th of 887 rated healthcare providers
Job description
Compassion. Accountability. Collaboration. Foresight. Joy.
These are the Aspirus Core Values; and we are looking for the BEST around to join us as we demonstrate those values Every. Single. Day.
Aspirus Health in Wausau, WI is seeking a FRAUD WASTE ABUSE ANALYST to join our ASPIRUS HEALTH PLAN team!
The FWA Analyst plays a critical role in protecting the organization from improper billing, abusive practices, and potential fraud. This position conducts detailed reviews of medical claims, provider patterns, and member activity to identify anomalies and ensure compliance with regulatory, contractual, and clinical standards.
The analyst will work closely with Senior Claims Analysts, the SIU, and cross-functional teams to support investigations, recommend corrective actions, and strengthen internal controls. A clinical background, particularly as an RN, along with utilization management and claims is strongly preferred to support accurate clinical interpretation of documentation and coding.
HOURS: Full-Time or 1.0 FTE, 80 hours every 2 weeks.
Experience/Qualifications
Required Qualifications
Preferred Qualifications
Employee Benefits
Our Mission: We heal people, promote health and strengthen communities.
Our Vision: Aspirus is a catalyst for creating healthy, thriving communities, trusted and engaged above all others.
As an Aspirus team, we demonstrate caring, we plan to impact the future, work with happiness and enthusiasm, recognize our power to make a difference and improve the health of our communities.
Aspirus Health is a nonprofit, community-directed health system based in Wausau, Wisconsin, serving northeastern Minnesota, northern and central Wisconsin and the Upper Peninsula of Michigan. The health system operates 18 hospitals and 130 outpatient locations with nearly 14,000 team members, including 1,300 employed physicians and advanced practice clinicians. For more information visit aspirus.org.
Click here to learn more.
These are the Aspirus Core Values; and we are looking for the BEST around to join us as we demonstrate those values Every. Single. Day.
Aspirus Health in Wausau, WI is seeking a FRAUD WASTE ABUSE ANALYST to join our ASPIRUS HEALTH PLAN team!
The FWA Analyst plays a critical role in protecting the organization from improper billing, abusive practices, and potential fraud. This position conducts detailed reviews of medical claims, provider patterns, and member activity to identify anomalies and ensure compliance with regulatory, contractual, and clinical standards.
The analyst will work closely with Senior Claims Analysts, the SIU, and cross-functional teams to support investigations, recommend corrective actions, and strengthen internal controls. A clinical background, particularly as an RN, along with utilization management and claims is strongly preferred to support accurate clinical interpretation of documentation and coding.
HOURS: Full-Time or 1.0 FTE, 80 hours every 2 weeks.
Experience/Qualifications
Required Qualifications
- Bachelor's degree is required.
- Active RN license is strongly preferred; LPN or other clinical credentials may be considered.
- Minimum of two years' experience in health insurance claims analysis or related experience required.
Preferred Qualifications
- Experience in SIU, FWA investigations, or compliance within a payer or provider environment.
- Knowledge of CPT, HCPCS, and ICD-10 coding and medical terminology.
- Familiarity with CMS, Medicare, and commercial plan regulations
- Strong analytical and problem-solving skills with the ability to interpret complex data sets.
- Excellent written and verbal communication skills for reporting and cross-department collaboration.
- Proficiency with claims platforms and data tools such as Facets, ClaimsXten, Excel, or similar systems.
- Background in clinical case management or utilization review.
Employee Benefits
- Full benefits packages available for part- and full-time status.
- Time away from work accrual.
- Retirement plans available.
- Wellness program for employees and their families.
Our Mission: We heal people, promote health and strengthen communities.
Our Vision: Aspirus is a catalyst for creating healthy, thriving communities, trusted and engaged above all others.
As an Aspirus team, we demonstrate caring, we plan to impact the future, work with happiness and enthusiasm, recognize our power to make a difference and improve the health of our communities.
Aspirus Health is a nonprofit, community-directed health system based in Wausau, Wisconsin, serving northeastern Minnesota, northern and central Wisconsin and the Upper Peninsula of Michigan. The health system operates 18 hospitals and 130 outpatient locations with nearly 14,000 team members, including 1,300 employed physicians and advanced practice clinicians. For more information visit aspirus.org.
Click here to learn more.
What Aspirus Health employees say
Pay
Benefits
Hours and flexibility
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About Aspirus
Sourced by ZipRecruiter
Industry
Hospitals
Company size
10,000+ Employees
Headquarters location
Wausau, WI, US
Year founded
1886