Case Manager - Utilization Review Specialist - Remote

Quorum Health; Nashville (TN); Remote; USD 85,000 - 110,000; Full time

Job summary

Quorum Health Corporation is seeking an experienced Utilization Review Specialist (Case Manager) to join our remote team. The role focuses on admission and concurrent reviews to prevent denials and improve workflow through root-cause analysis.

You must have a current RN license and extensive experience in case management, discharge planning, and utilization review, with knowledge of InterQual criteria and payer regulations. HIPAA compliance is essential.

Qualifications

• Significant healthcare experience required, including five years as a clinical nurse in an acute care setting.
• At least five to seven years in case management, discharge planning, and/or utilization review preferred.
• Knowledge of regulatory and payer requirements for Case Management activities.
• Ability to evaluate discharge planning for complex cases and use established criteria to support appeals.

Responsibilities

• Analyze patient records to determine admission needs and length of stay according to government and payer policies.
• Assess standards from insurance, government, and accrediting bodies for admissions and care.
• Approve admissions or refer to utilization review committee when criteria are not met.
• Coordinate first to third level appeals and assign reviews to physician advisors and medical directors.
• Ensure documentation of denials and maintain data for reporting and QA activities.
• Support timely appeals and collaborate with other departments to resolve issues.

Skills

RN license

Case management

Discharge planning

Utilization review

HIPAA compliance

Regulatory knowledge

Education

Nursing degree (RN)

Tools

InterQual Criteria

Milliman & Robertson Criteria

Job description

Case Manager - Utilization Review Specialist - RemoteFull-Time Position

You must reside in one of these states to be eligible for position:Arkansas California KentuckyMassachusetts Nevada New MexicoOregon Utah TennesseeTexas Wyoming

The Utilization Review Specialist assumes responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers, as well as appeals of all accounts reviewed and deemed appropriate for appeal. The Specialist will create a structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements.

EDUCATION/TRAINING & EXPERIENCE

Current state-issued RN license. Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.

KEY JOB RESPONSIBILITIES

• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies:
• Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
• Abstracts data from records and maintains statistics.
• Determines patient review dates according to established diagnostic criteria.
• May assist the review committee in planning and holding federally mandated quality assurance reviews.
• May supervise and coordinate activities of utilization review staff.
• Research clinical records, appropriate insurance regulations and history of claim to determine next stepMonitor day to day compliance of appeal decision time frames and collaborate with other departments to ensure timely resolution of issues or appeals.
• Review clinical and medical records for completeness and determine administrative or clinical appeal.
• Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews.
• Coordinate first, second and third level appeals.
• Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
• Ensure proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties.
• Manage appeals to ensure timely submissions.
• Monitor volume of appeals in order to engage additional resources when needed.
• Form professional relationships with payer appeals and utilization departments.
• Enter all data related to appeals and case reviews into a database.
• Prepare and present information on appeals to applicable committees and personnel as requested.
• Prepare for and complete appeals audits.
• Monitor and report QI (Quality Improvement) activities of appeals department.
• Demonstrate ability to draft professional appeal letter by incorporating supporting documents, policies and statutes.
• Other duties as assigned.

EXPERIENCE / SKILLS

• Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting.
• In addition, having at least five to seven years of experience in case management, discharge planning, and/or utilization review is preferred.
• Knowledge of regulatory and payer requirements for Case Management Activities.
• Ability to critically evaluate and make decisions about whether discharge planning for highly difficult cases
• Ability to use pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support one’s own clinical appeals arguments
• Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations.
• Ability to read, evaluate, and abstract important information from handwritten patient medical records.
• Excellent oral and technical writing and typing skills.
• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task‑related priorities.
• Ability to successfully work independently and to adapt quickly to changing priorities and regulations. Excellent oral and technical writing skills and the Ability to maintain confidentiality according to HIPAA regulations is required.
• Other duties as assigned.