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Utilization Review Np Jobs in Wisconsin (NOW HIRING)

Heartland Hospice

Nurse Practitioner

Stevens Point, WI · On-site

... care utilization. * Prescribe medications and treatments, including controlled substances, as ... Communicate findings, treatment plans, diagnostics, and medication reviews with IDG/IDT. * Provide ...

Gentiva Hospice

Nurse Practitioner

Stevens Point, WI · On-site

... care utilization. * Prescribe medications and treatments, including controlled substances, as ... Communicate findings, treatment plans, diagnostics, and medication reviews with IDG/IDT. * Provide ...

Gentiva

Hospice Nurse Practitioner

Stevens Point, WI

... care utilization. * Prescribe medications and treatments, including controlled substances, as ... Communicate findings, treatment plans, diagnostics, and medication reviews with IDG/IDT. * Provide ...

Preferred Podiatry Group

Nurse Practitioner

Madison, WI · On-site

$110K - $170K/yr

Nurse Practitioner - Long-Term Care Part-Time or Full-Time | Flexible Schedule | Greater Clinical ... to review and approval by the Wisconsin Board of Nursing. Candidates whose practice currently ...

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Utilization Review Np information

What does a utilization review nurse practitioner do?

A Utilization Review Nurse Practitioner (NP) evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance coverage to ensure that care meets established guidelines and regulatory requirements. Utilization Review NPs help coordinate care, prevent unnecessary procedures, and support cost-effective healthcare delivery while ensuring patient safety and quality outcomes.

What are some common challenges utilization review nurse practitioners face when collaborating with healthcare providers and insurance companies?

Utilization Review Nurse Practitioners often navigate the challenge of balancing patient advocacy with payer requirements. They must effectively communicate clinical justifications to both healthcare providers and insurance representatives, sometimes mediating disagreements over the necessity of certain treatments or hospital stays. Staying up-to-date with ever-changing insurance guidelines and ensuring timely documentation can also be demanding, but strong organizational and interpersonal skills help facilitate smooth collaboration and successful patient outcomes.

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

To thrive as a Utilization Review Nurse Practitioner (NP), you need expert clinical judgment, a strong understanding of healthcare regulations, and advanced assessment skills, typically supported by an active NP license and clinical experience. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines such as Medicare and Medicaid are commonly required. Excellent communication, attention to detail, and critical thinking are vital soft skills for effective case evaluations and collaboration with providers. These competencies ensure accurate, efficient reviews that support quality care, compliance, and cost-effective treatment decisions.

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

AspectUtilization Review NpUtilization Review Nurse
CredentialsMaster's degree in Nursing, Nurse Practitioner certification, state licensureRegistered Nurse (RN) license, possibly with certification in utilization review
Work EnvironmentHealthcare facilities, insurance companies, utilization review organizationsHospitals, insurance companies, outpatient clinics
Job ResponsibilitiesAssess medical necessity, authorize treatments, make clinical decisions, often with greater autonomyReview medical records, support authorization processes, follow established guidelines

Utilization Review NPs typically have advanced clinical training and greater decision-making authority compared to Utilization Review Nurses. Both roles focus on evaluating medical necessity, but NPs often perform more complex assessments and can make independent recommendations, whereas nurses support the review process under supervision or guidelines.

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What job categories do people searching Utilization Review Np jobs in Wisconsin look for?

The top searched job categories for Utilization Review Np jobs in Wisconsin are:

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Cities in Wisconsin with the most Utilization Review Np job openings:

Utilization Review Np jobs near you
Infographic showing various Utilization Review Np job openings in Wisconsin as of August 2026, with employment types broken down into 5% As Needed, 58% Full Time, 26% Part Time, and 11% Contract. Highlights an 95% In-person, and 5% Remote job distribution.

Inpatient Utilization Review RN - 1.0FTE

Osceola Medical Center

Osceola, WI • On-site

Other

Posted 2 days ago

New

Job description

Summary:
OMC Core Behavior Standards:
Create Teamwork• Lead with Honesty & Integrity• Convey Compassion• Show Respect• Pursue Quality
Osceola Medical Center is committed to implementing these behavior standards as a foundation for how we hire, develop, and retain our team members. By intentionally selecting candidates whose values and behaviors align with these standards, we ensure that our mission is lived out every day, creating an environment where patients feel valued, respected, and confident that OMC is the place for all their healthcare needs.
Tentative Schedule:
Monday-Friday, Days: 8am-4:30pm
Job Summary:
The Inpatient Utilization Review RN is a key member of the healthcare team responsible for ensuring the appropriate utilization of hospital resources through concurrent review, medical necessity evaluation, payer communication, and regulatory compliance activities. This role collaborates with physicians, nursing staff, case management, and third-party payers to support optimal patient outcomes while ensuring appropriate admission status, level of care, and reimbursement.
The Inpatient Utilization Review RN also assists with care coordination and discharge planning activities to support efficient patient progression throughout the continuum of care.
Responsibilities include:
Utilization Review and Medical Necessity Determination
  • Perform concurrent reviews of inpatient, observation, swing bed, and other applicable patient stays to evaluate medical necessity and appropriate level of care.
  • Apply established criteria to support admission status and continued stay determinations.
  • Collaborate with providers to obtain documentation necessary to support medical necessity and reimbursement.
  • Identify opportunities to improve documentation and ensure accurate patient status designation.
  • Monitor length of stay and identify barriers to timely progression of care.
Payer Authorization and Denial Management
  • Obtain and maintain required payer authorizations for admissions, continued stays, procedures, and post-acute services.
  • Serve as liaison between the hospital, physicians, and insurance providers regarding utilization review activities.
  • Assist in the appeal process for denied services and work collaboratively with interdisciplinary teams to reduce avoidable denials.
  • Maintain current knowledge of payer requirements and reimbursement regulations.
Care Coordination and Discharge Planning
  • Collaborate with patients, families, providers, nursing staff, and community resources to facilitate safe and effective transitions of care.
  • Assist with discharge planning activities including referrals to post-acute services, home health agencies, rehabilitation facilities, and durable medical equipment providers.
  • Identify barriers to discharge and coordinate interventions to support timely patient transitions.
Patient and Family Education
  • Educate patients and families regarding care transitions, insurance requirements, available resources, and post-discharge services.
  • Promote patient understanding and engagement in discharge and follow-up plans.
Documentation and Regulatory Compliance
  • Maintain complete, accurate, and timely documentation in the electronic health record.
  • Ensure compliance with CMS Conditions of Participation, Critical Access Hospital regulations, payer requirements, and organizational policies.
  • Participate in audits, quality improvement initiatives, and regulatory reviews as needed.
  • Track and report utilization review metrics, trends, and opportunities for improvement.
Knowledge, Skills, and Abilities
  • Strong knowledge of utilization review principles, medical necessity criteria, reimbursement methodologies, and regulatory requirements.
  • Understanding of CMS, Medicare, Medicaid, and commercial payer guidelines.
  • Proficiency with electronic health records and Microsoft Office applications.
  • Strong critical thinking, clinical judgment, and analytical skills.
  • Excellent communication, negotiation, and collaboration abilities.
  • Ability to work independently while managing multiple priorities and deadlines.
  • Knowledge of discharge planning and care coordination processes.
Physical Requirements for the Role:
  • Sitting and standing associated with a normal office environment
  • Some bending, stooping, and stretching
  • Able to use office equipment such as copier, computer, telephone and fax machine
  • Able to lift 5-10 lbs frequently, 20 lbs occasionally.
  • Hand dexterity for office machine operation, mobility to complete errands, or sitting for extended periods of time
  • Adequate vision, hearing and speaking abilities to perform essential duties, including telephone communication
  • Able to prioritize activities when faced with competing demands
Qualifications:
  • Graduate of an accredited nursing program.
  • Current Wisconsin Registered Nurse (RN) license required.
  • Bachelor's degree in nursing (BSN) preferred.
  • Minimum of three (3) years of clinical nursing experience in acute care required.
  • Previous experience in utilization review, case management, care coordination, revenue cycle, or discharge planning preferred.
  • Experience working with Medicare, Medicaid, and commercial insurance plans preferred.
  • Familiarity with Critical Access Hospital regulations required.
  • Certified Case Manager (CCM), Accredited Case Manager (ACM), or utilization review certification preferred.
  • 3 years acute care experience

Work Environment:
The Inpatient Utilization Review RN functions in a collaborative clinical and administrative environment requiring frequent interaction with providers, nursing staff, patients, families, payers, and community agencies. Work involves detailed chart review, documentation analysis, payer communication, and interdisciplinary care coordination. The role may require flexible scheduling to meet organizational and patient care needs.
Why Join OMC?
At OMC, we don't just hire for skills-we hire for behaviors that align with our mission. We invest in team members who are committed to making a meaningful difference in the lives of our patients and in the communities we serve.

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