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Utilization Review Case Manager Jobs in Appleton, WI

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 ...

Network Health

Associate Medical Director

Menasha, WI · On-site

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 ...

JBS Imports

OCCUPATIONAL HEALTH MANAGER

Green Bay, WI · On-site

Establishes, maintains, and reviews a record keeping system that ensures confidentiality. Adheres ... and case management. Also provides first aid, minor treatment, counseling, referral and medical ...

JBS USA

OCCUPATIONAL HEALTH MANAGER

Green Bay, WI · On-site

Establishes, maintains, and reviews a record keeping system that ensures confidentiality. Adheres ... and case management. Also provides first aid, minor treatment, counseling, referral and medical ...

JBS USA

OCCUPATIONAL HEALTH MANAGER

Green Bay, WI

Establishes, maintains, and reviews a record keeping system that ensures confidentiality. Adheres ... and case management. Also provides first aid, minor treatment, counseling, referral and medical ...

Unity Hospice

Operations Manager

Green Bay, WI · Hybrid

Lead labor utilization and productivity initiatives across nursing service lines. * Analyze ... Ensure payroll accuracy through timecard audits and exception reviews. * Collaborate with Finance ...

Unity Hospice

Operations Manager

Green Bay, WI · On-site

Lead labor utilization and productivity initiatives across nursing service lines. * Analyze ... Ensure payroll accuracy through timecard audits and exception reviews. * Collaborate with Finance ...

Unity Hospice

Operations Manager

Green Bay, WI · On-site

Lead labor utilization and productivity initiatives across nursing service lines. * Analyze ... Ensure payroll accuracy through timecard audits and exception reviews. * Collaborate with Finance ...

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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

$16

$35

$58

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

As of Jul 19, 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
Associate Medical Director

Associate Medical Director

Network Health

Menasha, WI • On-site, Remote

Full-time

Posted 24 days ago

Job description

In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.

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 is required occasionally for the position.

Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday, weekend coverage required on rotational basis

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:

  • Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers
  • Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards
  • Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs. 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 assessment processes
  • Provide medical consultation as requested for:
    • Medical/legal issues
    • Member grievance procedures
    • Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts
    • Medical issues related to contract negotiations with health care providers
    • Determining if services to members/enrollees meet medical criteria
  • Promote positive relationship between NHP and medical community
  • Serve as liaison between NHP and providers regarding matters of medical policy and medical administration
  • Serve as spokesperson for NHP in the medical community and maintains appropriate contact with  professional health care organizations
  • Participates in the ongoing recruitment of plan physicians.
  • Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors
  • Assist in the development of appropriate medical guidelines and parameters for claims review
  • Assist in the training of NHP staff on matters relating to medical guidelines
  • Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness
  • Perform second level review of provider appeals and disputes
  • Serve on committees as coordinated with the CMO
  • Assist in strategic planning targeted towards plan growth initiatives

Job Requirements:

  • Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction

  • Member in good standing of the local medical community. An active practitioner of medicine in the NHP service areas

  • Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service area

  • Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity

  • Board certified in an ABMS medical specialty required

Network Health is an Equal Opportunity Employer

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