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Utilization Review Np Jobs in Wisconsin (NOW HIRING)

Heartland Hospice

Nurse Practitioner

Stevens Point, WI · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... 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

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

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

Heartland Hospice

Hospice Nurse Practitioner

Eau Claire, WI · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

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

Heartland Hospice

Hospice Nurse Practitioner

Stevens Point, WI

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... 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

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

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

Heartland of Perrysburg

Hospice Nurse Practitioner

Eau Claire, WI · On-site

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

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

One Vision International

Nurse Practitioner

Green Bay, WI · On-site

$120/hr

Please review the and APPLY if you're interested in this position! Job Title: Nurse Practitioner Pay range: $105/hr. on W2 or $120/hr. on 1099 Locations : Green Bay, WI | Plymouth, WI | Union Grove ...

One Vision International

Nurse Practitioner

Portage, WI · On-site

$120/hr

Please review the and APPLY if you're interested in this position! Job Title: Nurse Practitioner Pay range: $105/hr. on W2 or $120/hr. on 1099 Locations : Green Bay, WI | Plymouth, WI | Union Grove ...

One Vision International

Nurse Practitioner

Plymouth, WI · On-site

$120/hr

Please review the and APPLY if you're interested in this position! Job Title: Nurse Practitioner Pay range: $105/hr. on W2 or $120/hr. on 1099 Locations : Green Bay, WI | Plymouth, WI | Union Grove ...

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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.

What are popular job titles related to Utilization Review Np jobs in Wisconsin?

For Utilization Review Np jobs in Wisconsin, the most frequently searched job titles are:

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:

What cities in Wisconsin are hiring for Utilization Review Np jobs?

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.

RN Coordinator Utilization Management

Network Health, Inc

Menasha, WI

Full-time

Re-posted 12 days ago

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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