Remote Case Manager: Utilization Review & Appeals

Jobgether; Arkansas; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote work

Professional collaboration

Paid time off

Retirement plans

Job summary

Jobgether, in partnership with a healthcare client, seeks an experienced Case Manager – Utilization Review Specialist for a fully remote role in the United States. You will lead admission and concurrent reviews, assess medical necessity, and coordinate multi-level appeals to optimize patient care and reimbursement outcomes.

You will leverage your nursing expertise to evaluate records, ensure regulatory compliance, and collaborate with physicians, directors, and payer representatives to improve

Qualifications

• Active RN license in a U.S. state is required.
• Minimum five years of clinical nursing in an acute care setting.
• Five to seven years in case management, discharge planning, utilization review, or related area preferred.
• Strong knowledge of utilization management, payer policies, and regulations.
• Familiarity with InterQual and Milliman & Robertson (MCG) guidelines preferred.

Responsibilities

• Conduct admission and concurrent utilization reviews for medical necessity and LOS.
• Analyze medical records and payer policies to determine compliance with criteria.
• Identify reimbursement denials and develop prevention strategies through workflow improvements.
• Review documentation to determine next steps and appeals.
• Coordinate first-, second-, and third-level appeals with timely submissions.
• Draft appeal letters with clinical evidence and payer policies.
• Monitor timelines, outcomes, and collaborate with departments for issue resolution.
• Maintain accurate documentation in databases and billing systems.
• Establish relationships with payer utilization management and appeals departments.

Skills

RN license

Acute care nursing

Case management

Payer requirements

Clinical decision-support (InterQual,

Communication

Tools

InterQual

Milliman & Robertson

Job description

Jobgether, in partnership with a healthcare client, seeks an experienced Case Manager – Utilization Review Specialist for a fully remote role in the United States. You will lead admission and concurrent reviews, assess medical necessity, and coordinate multi-level appeals to optimize patient care and reimbursement outcomes.

You will leverage your nursing expertise to evaluate records, ensure regulatory compliance, and collaborate with physicians, directors, and payer representatives to improve