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Utilization Management Nurse Jobs in Appleton, WI

TEEMA Group

Registered Nurse (RN)

Oshkosh, WI · On-site

$53 - $60/hr

Infirmary Management: Monitor, evaluate, and provide dedicated care to complex patients housed ... Prior professional experience navigating behavioral health, substance utilization programs, or ...

TEEMA Group

Registered Nurse (RN)

Green Bay, WI · On-site

$55 - $63/hr

Infirmary Management: Monitor, evaluate, and provide dedicated care to complex patients housed ... Prior professional experience navigating behavioral health, substance utilization programs, or ...

TEEMA Group

Registered Nurse (RN)

Green Bay, WI · On-site

$55 - $63/hr

Infirmary Management: Monitor, evaluate, and provide dedicated care to complex patients housed ... Prior professional experience navigating behavioral health, substance utilization programs, or ...

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All JobsUtilization Management Nurse JobsUtilization Management Nurse Jobs in Appleton, WI

Utilization Management Nurse information

See Appleton, WI salary details

$38.1K

$87.3K

$159K

How much do utilization management nurse jobs pay per year?

As of Sep 6, 2026, the average yearly pay for utilization management nurse in Appleton, WI is $87,311.00, according to ZipRecruiter salary data. Most workers in this role earn between $62,900.00 and $102,000.00 per year, depending on experience, location, and employer.

What is a utilization management nurse?

A Utilization Management Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services provided to patients. They review medical records and treatment plans to ensure that care meets established guidelines and is cost-effective. Utilization Management Nurses work with healthcare providers, insurance companies, and patients to coordinate care and prevent unnecessary procedures or hospitalizations. Their goal is to support high-quality patient care while managing healthcare costs.

What does a utilization management nurse do?

A utilization management nurse ensures that healthcare services are administered appropriately. Their job responsibilities include working in a hospital, health practice, or other clinical setting reviewing patient clinical records, drafting clinical appeals, and overseeing staff members. The qualifications for a utilization management nurse include a nursing degree and a registered nursing license. Most people in this job also have career experience in case management and utilization review.

What are the key skills and qualifications needed to thrive as a utilization management nurse?

To thrive as a Utilization Management Nurse, you need a registered nursing license, strong clinical judgment, and experience in case management or utilization review. Familiarity with medical management software, InterQual or Milliman guidelines, and insurance authorization processes is typically required. Excellent analytical thinking, communication, and negotiation skills help you coordinate with providers and advocate for patients. These competencies ensure appropriate resource use, compliance with regulations, and optimal patient outcomes.

What are some common challenges a utilization management nurse faces when coordinating care between providers and insurance companies?

A Utilization Management Nurse often navigates the challenge of balancing patient advocacy with insurance guidelines, ensuring that care recommendations meet both clinical standards and payer requirements. Communicating complex medical information to both providers and insurance representatives can be demanding, especially when there are disagreements about coverage or medical necessity. Additionally, staying updated on changing policies and maintaining thorough documentation under tight deadlines are frequent aspects of the role. Strong collaboration skills and attention to detail are essential for success in this position.

What is the difference between Utilization Management Nurse vs Case Manager?

AspectUtilization Management NurseCase Manager
CredentialsRN license, certifications in utilization reviewRN license, case management certification often preferred
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, community health agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of servicesCoordinating patient care and discharge planning

Utilization Management Nurses primarily focus on reviewing medical necessity and approving healthcare services, while Case Managers coordinate patient care and facilitate discharge planning. Both roles require RN licensure and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.

More about Utilization Management Nurse jobs

What are the most commonly searched types of Utilization Management Nurse jobs in Appleton, WI?

The most popular types of Utilization Management Nurse jobs in Appleton, WI are:

What are popular job titles related to Utilization Management Nurse jobs in Appleton, WI?

For Utilization Management Nurse jobs in Appleton, WI, the most frequently searched job titles are:

What job categories do people searching Utilization Management Nurse jobs in Appleton, WI look for?

The top searched job categories for Utilization Management Nurse jobs in Appleton, WI are:

What cities near Appleton, WI are hiring for Utilization Management Nurse jobs?

Cities near Appleton, WI with the most Utilization Management Nurse job openings:

Utilization Management Nurse jobs near you
Infographic showing various Utilization Management Nurse job openings in Appleton, WI as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 15% Part Time, and 2% Contract. Highlights an 90% Physical, 2% Hybrid, and 8% Remote job distribution, with an average salary of $87,311 per year, or $42 per hour.

RN Coordinator Utilization Management

Network Health

Menasha, WI • On-site

Full-time

Re-posted 2 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

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