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Utilization Review Director 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 ...

CVS Health

Grad Pharmacist

Green Bay, WI · On-site

$16.25 - $20.25/hr

... quality assurance drug utilization review (DUR), pharmacy professional standards such as ... Completing basic inventory activities, as permitted by law, and as directed by the pharmacy ...

Pick 'n Save

PHARMACY/PHARMACIST LEADER

Appleton, WI

$55.75 - $67.25/hr

... Direct the pharmacy team to achieve warehouse utilization goals, avoid unnecessary overstock ... reviews and provide direct feedback to direct reports - Must be able to perform the essential job ...

T Mart

Regional Supervisor

Appleton, WI · On-site

... and employee utilization and morale * Reviews weekly checklists for efficiency in product ... via the Director of Operations, yourself, the Company Newsletter, and our suppliers. Ensure ...

Baskin Robbins

Regional Supervisor

Appleton, WI

... and employee utilization and morale * Reviews weekly checklists for efficiency in product ... via the Director of Operations, yourself, the Company Newsletter, and our suppliers.Ensure ...

Dunkin Donuts

Regional Supervisor

Appleton, WI · On-site

... and employee utilization and morale * Reviews weekly checklists for efficiency in product ... via the Director of Operations, yourself, the Company Newsletter, and our suppliers. Ensure ...

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All JobsUtilization Review JobsUtilization Review Director JobsUtilization Review Director Jobs in Appleton, WI

Utilization Review Director information

See Appleton, WI salary details

$20

$41

$67

How much do utilization review director jobs pay per hour?

As of Aug 6, 2026, the average hourly pay for utilization review director in Appleton, WI is $41.26, according to ZipRecruiter salary data. Most workers in this role earn between $32.60 and $47.36 per hour, depending on experience, location, and employer.

What is the difference between Utilization Review Director vs Utilization Review Nurse?

AspectUtilization Review DirectorUtilization Review Nurse
CredentialsRN license, management experience, certifications (e.g., CCM)RN license, certification in case management or utilization review (e.g., CUC)
Work EnvironmentAdministrative, leadership roles overseeing teamsClinical, review of patient cases, direct patient care
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentLeadership, management, strategic planning in utilization reviewClinical review, case assessment, patient care coordination

The Utilization Review Director typically oversees review teams and manages utilization strategies, requiring leadership skills and management experience. In contrast, the Utilization Review Nurse focuses on clinical case assessments and patient care reviews. Both roles require RN licensure and relevant certifications but differ mainly in scope and responsibilities.

What does a utilization review director do?

A Utilization Review Director oversees the evaluation of medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead teams that review patient care requests, manage compliance with regulations, and implement strategies to ensure cost-effective care without compromising quality. Their responsibilities often include policy development, data analysis, and collaboration with healthcare providers to optimize resource use and improve patient outcomes.

Is utilization review a stressful job?

Utilization Review Directors often work in high-pressure environments where they must make quick, accurate decisions regarding healthcare services. The role can be stressful due to the need to balance patient care, insurance policies, and regulatory compliance, but stress levels vary based on workload, organizational support, and experience. Strong analytical skills and certification in utilization review can help manage job demands effectively.

What degree do I need for utilization review director?

A utilization review director typically needs at least a bachelor's degree in healthcare administration, nursing, or a related field. Many employers prefer candidates with a master's degree such as an MBA or a healthcare-related advanced degree, along with relevant experience and certifications like the Certified Professional in Healthcare Quality (CPHQ).

What are some common challenges faced by a utilization review director, and how can they be addressed?

A Utilization Review Director often navigates challenges such as balancing regulatory compliance with organizational goals, managing interdisciplinary teams, and keeping up with evolving healthcare policies. Staying proactive with ongoing education, fostering open communication among staff, and implementing efficient review processes can help address these issues. Additionally, leveraging data analytics and technology streamlines case reviews and ensures evidence-based decision-making, ultimately improving both patient outcomes and operational efficiency.

What are the key skills and qualifications needed to thrive as a utilization review director, and why are they important?

To thrive as a Utilization Review Director, you need a deep understanding of clinical guidelines, healthcare regulations, and case management principles, typically supported by a nursing or related healthcare degree and relevant licensure. Familiarity with utilization management software, electronic health records (EHR), and certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) is common in the field. Strong leadership, communication, analytical thinking, and decision-making skills help you effectively manage teams and ensure compliance. These competencies ensure efficient resource use, regulatory adherence, and high-quality patient outcomes within healthcare organizations.
What are the most commonly searched types of Utilization Review jobs in Appleton, WI? The most popular types of Utilization Review jobs in Appleton, WI are:
Utilization Review Director jobs near you

Associate Medical Director

Network Health

Menasha, WI • On-site, Remote

Full-time

Re-posted 12 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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