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Utilization Review Rn Jobs in Appleton, WI (NOW HIRING)

TEEMA Group

Registered Nurse (RN)

Oshkosh, WI · On-site

$55 - $60/hr

Registered Nurse (RN)Role Summary Are you a resilient, highly analytical Registered Nurse looking ... Prior professional experience navigating behavioral health, substance utilization programs, or ...

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Avina of Weyauwega

PM Registered Nurse (RN)

Weyauwega, WI · On-site

$38 - $40/hr

FT RN $40/hour Registered Nurse (RN) Job Benefits: * Competitive Pay * Health Insurance including ... Review medication orders for completeness of information and accuracy. * Transcribe physician ...

Avina of Weyauwega

PM Registered Nurse (RN)

Weyauwega, WI · On-site

$38 - $40/hr

FT RN $40/hour Registered Nurse (RN) Job Benefits: * Competitive Pay * Health Insurance including ... Review medication orders for completeness of information and accuracy. * Transcribe physician ...

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Carepros, LLC

Registered Nurse

Appleton, WI

The plan shall be based on the RN's visit to the Client's home and shall include: · Review and interpretation of the physician's orders. · Frequency and anticipated duration of service. · ...

Carepros, LLC

Registered Nurse

Appleton, WI · On-site

The plan shall be based on the RN's visit to the Client's home and shall include: · Review and interpretation of the physician's orders. · Frequency and anticipated duration of service. · ...

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Carepros, LLC

Registered Nurse

Appleton, WI · On-site

The plan shall be based on the RN's visit to the Client's home and shall include: • Review and interpretation of the physician's orders. • Frequency and anticipated duration of service. • ...

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 ...

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

Utilization Review Rn information

See Appleton, WI salary details

$20

$41

$67

How much do utilization review rn jobs pay per hour?

As of Jul 6, 2026, the average hourly pay for utilization review rn 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.

How to get into utilization review as a nurse?

To become a utilization review RN, candidates typically need a valid nursing license and experience in clinical settings. Additional certifications such as Certified Professional in Healthcare Quality (CPHQ) or case management credentials can enhance prospects, and familiarity with electronic health records and insurance policies is beneficial.

How does a Utilization Review RN collaborate with physicians and other healthcare professionals during the patient care review process?

A Utilization Review RN works closely with physicians, case managers, and other healthcare team members to ensure that patients receive appropriate care while adhering to regulatory and insurance guidelines. This collaboration often involves discussing clinical findings, clarifying documentation, and negotiating care plans to meet both patient needs and payer requirements. Effective communication and teamwork are essential, as Utilization Review RNs frequently serve as liaisons between clinical staff and insurance representatives to facilitate timely authorizations and prevent unnecessary delays in patient care.

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

To thrive as a Utilization Review RN, you need a current RN license, strong clinical assessment skills, and knowledge of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or ACM is often required. Excellent critical thinking, communication, and negotiation skills help you advocate for appropriate patient care while collaborating with providers and payers. These skills ensure cost-effective, quality care and compliance with regulatory standards in healthcare delivery.

How to make $300,000 as a nurse?

A Utilization Review RN can earn $300,000 by gaining extensive experience, obtaining certifications such as Certified Review Officer (CRO), working in high-paying settings like insurance companies or managed care organizations, and taking on leadership or specialized roles that offer higher compensation. Advanced skills in clinical assessment, documentation, and understanding of healthcare policies can also contribute to higher earnings.

What does an RN utilization review do?

An RN utilization review evaluates medical records and treatment plans to determine the necessity, appropriateness, and efficiency of healthcare services. They ensure compliance with insurance policies and clinical guidelines, often using electronic health records and requiring knowledge of coding and documentation standards. This role supports cost-effective patient care and involves collaboration with healthcare providers and insurance companies.

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

AspectUtilization Review RnCase Manager
CredentialsRN license, certifications in utilization reviewRN license, certifications in case management
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, community agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of careCoordinating patient care and discharge planning

Utilization Review Rns primarily focus on evaluating the necessity of medical treatments, while Case Managers coordinate patient care and discharge planning. Both roles require RN licensure and certifications, but their daily responsibilities and work environments differ slightly, with Utilization Review Rns concentrating on review processes and Case Managers on patient advocacy and care coordination.

How to make $150,000 as a nurse?

A Utilization Review RN can earn $150,000 by gaining extensive experience, obtaining certifications such as Certified Review Officer (CRO), working in high-demand settings, and possibly taking on leadership or specialized roles. Increasing your workload, working overtime, or pursuing advanced education can also contribute to higher earnings within this field.

What is a Utilization Review RN?

A Utilization Review RN is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, collaborate with healthcare teams, and ensure that patient care meets established guidelines and payer requirements. Their role helps control costs, optimize care, and support compliance with healthcare regulations. Utilization Review RNs often work in hospitals, insurance companies, or managed care organizations.
What are the most commonly searched types of Utilization Review Rn jobs in Appleton, WI? The most popular types of Utilization Review Rn jobs in Appleton, WI are:
What are popular job titles related to Utilization Review Rn jobs in Appleton, WI? For Utilization Review Rn jobs in Appleton, WI, the most frequently searched job titles are:
What job categories do people searching Utilization Review Rn jobs in Appleton, WI look for? The top searched job categories for Utilization Review Rn jobs in Appleton, WI are:
What cities near Appleton, WI are hiring for Utilization Review Rn jobs? Cities near Appleton, WI with the most Utilization Review Rn job openings:
Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Appleton, WI as of June 2026, with employment types broken down into 2% As Needed, 58% Full Time, 3% Part Time, 1% Temporary, 35% Contract, and 1% Nights. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution, with an average salary of $85,812 per year, or $41.3 per hour.
RN Coordinator Utilization Management

RN Coordinator Utilization Management

Network Health WI

Menasha, WI • On-site, Remote

Full-time

Posted 29 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
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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