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Utilization Review Case Manager Jobs in Appleton, WI

Network Health WI

RN Care Manager

Menasha, WI · On-site +1

Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...

Network Health

RN Care Manager

Menasha, WI · Remote

Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...

Network Health, Inc

RN Care Manager

Menasha, WI · Remote

Review results from medical or behavioral tests and procedures and updates care plan to reflect ... Previous experience in case management, utilization management, insurance, or managed care ...

Bellin

Pharmacist - Inpatient Pharmacy

Green Bay, WI · On-site

$56.75 - $68/hr

... management, application of therapeutic interchanges, drug utilization review, efficient drug distribution processes, computerized provider order entry (CPOE) order review and verification, medication ...

Bellin

Pharmacist - Retail Pharmacy

Green Bay, WI · On-site

$56.75 - $68/hr

... management, application of therapeutic interchanges, drug utilization review, efficient drug distribution processes, computerized provider order entry (CPOE) order review and verification, medication ...

Network Health

Associate Medical Director

Menasha, WI · On-site +1

In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality ...

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All JobsUtilization Review Case JobsUtilization Review Case Manager JobsUtilization Review Case Manager Jobs in Appleton, WI

Utilization Review Case Manager information

See Appleton, WI salary details

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$35

$58

How much do utilization review case manager jobs pay per hour?

As of Jul 18, 2026, the average hourly pay for utilization review case manager in Appleton, WI is $35.60, according to ZipRecruiter salary data. Most workers in this role earn between $28.85 and $37.55 per hour, depending on experience, location, and employer.

What are some common challenges Utilization Review Case Managers face when coordinating care across multiple departments?

Utilization Review Case Managers often navigate complex communication between physicians, nursing staff, insurance providers, and patients to ensure appropriate care and resource use. Balancing timely authorizations with evolving patient needs and varying documentation standards can be challenging. Additionally, staying current with changing regulations and payer requirements requires ongoing learning and adaptability. Building strong collaborative relationships and maintaining clear, concise documentation are key strategies for overcoming these hurdles.

What is a Utilization Review Case Manager?

A Utilization Review Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical treatments and services provided to patients. They review clinical information, coordinate with providers and insurance companies, and ensure that patient care aligns with established guidelines and policies. Their goal is to optimize patient outcomes while managing healthcare costs and ensuring compliance with regulations.

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

AspectUtilization Review Case ManagerUtilization Review Nurse
CredentialsTypically requires a nursing license or relevant healthcare certificationRegistered Nurse (RN) license is required
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinic, insurance review departments
Primary FocusReviewing medical necessity, coordinating care, managing casesAssessing medical records, clinical review, patient care evaluation

Both roles involve healthcare review and require nursing credentials, but the Utilization Review Case Manager often focuses on coordinating care and managing cases, while the Utilization Review Nurse emphasizes clinical assessment and review of medical records. Understanding these differences helps in choosing the right career path or job search focus.

What are the key skills and qualifications needed to thrive as a Utilization Review Case Manager, and why are they important?

To thrive as a Utilization Review Case Manager, you need a clinical background such as an RN or LCSW license, strong knowledge of medical necessity criteria, and experience with case management. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of regulatory guidelines like Medicare and Medicaid are essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration between patients, providers, and payers. These skills ensure appropriate resource use, compliance with regulations, and high-quality patient care.
What are popular job titles related to Utilization Review Case Manager jobs in Appleton, WI? For Utilization Review Case Manager jobs in Appleton, WI, the most frequently searched job titles are:
What job categories do people searching Utilization Review Case Manager jobs in Appleton, WI look for? The top searched job categories for Utilization Review Case Manager jobs in Appleton, WI are:
What cities near Appleton, WI are hiring for Utilization Review Case Manager jobs? Cities near Appleton, WI with the most Utilization Review Case Manager job openings:
Utilization Review Case Manager jobs near you
RN Care Manager

RN Care Manager

Network Health WI

Menasha, WI • On-site, Remote

Full-time

Re-posted 13 days ago

Job description

The Registered Nurse Care Manager provides case management services that are member-centric and include assessment, planning, facilitation, care coordination, evaluation and advocacy to all members across the healthcare continuum. The Care Manager advocates for options and services to meet an individual's and family's comprehensive health needs through communication and coordination of available resources to promote quality, cost-effective outcomes.
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.
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:
  • Screen candidates for case management and when appropriate completes assessments, care plans with prioritized goals, interventions, and timeframes for re-assessment using evidence-based clinical guidelines. Evaluate and determine member needs based on clinical or behavioral information such as diagnosis, disease progression, procedures and other related therapies
  • Review results from medical or behavioral tests and procedures and updates care plan to reflect progress towards goals; close cases when expected goals/outcomes are achieved
  • Provide information and outreach regarding case or condition management activities to members, caregivers, providers and their administrative staff
  • Evaluate and process member referrals from physicians to other specialty providers
  • Assess, plan, facilitate and advocate for individuals to identify quality, cost effective interventions services and resources to ensure health needs are met
  • Works with members and families on self-management approaches using coaching techniques such as motivational interviewing
  • Educate the individual, his/her family and caretakers about case and condition management, the individual's health condition(s), medications, provider and community resources and insurance benefits to support quality, cost effective health outcomes.
  • Facilitate the coordination, communication and collaboration of the individual's care among his/her providers including tertiary, non-plan providers and community resources with the goal of controlling costs and improving quality.
  • Schedule visits with the individual and participates in facility-based care conferences as appropriate to ensure quality care, appropriate use of services, and transition planning.
  • Stay abreast of current best practices and new developments
  • Other duties as assigned

Job Requirements:
  • Graduation from accredited school of nursing
  • Bachelor's degree in Nursing preferred
  • RN licensure in the State of Wisconsin
  • Case Management certification preferred
  • Four years of clinical health care experience as a RN required
  • Previous experience in case management, utilization management, insurance, or managed care preferred
  • Experience with Medicare, Medicaid preferred

Network Health is an Equal Opportunity Employer
Equal Opportunity Employer
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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