Remote Case Manager, Utilization Review & Appeals

Quorum Health Corporation; Lexington (KY); Remote; USD 65,000 - 90,000; Full time

Job summary

Quorum Health Corporation is seeking a remote Utilization Review Specialist (Case Manager) to support admission decisions and appeals. The role requires an RN license and strong knowledge of criteria sets to support clinical appeals and quality reviews.

Responsibilities include reviewing patient records, coordinating appeals, and ensuring timely documentation and reporting while coordinating with payer and hospital staff. This is a remote, full-time position with state residency eligibility.

Qualifications

• State-issued RN license is required to practice in nursing and for utilization review.
• Knowledge of InterQual/ Milliman criteria and payer regulations is preferred.
• Experience in utilization review, discharge planning or case management is valuable.

Responsibilities

• Analyze patient records to determine admission legitimacy and length of stay per policies.
• Review standards from insurance and accrediting bodies to apply admission criteria.
• Approve admissions or refer to utilization review committee when criteria are not met.
• Abstract data from records and maintain statistics for reporting.
• Coordinate first to third level appeals and track appeal outcomes.
• Ensure documentation of all denials in billing systems and monitor timelines.

Skills

Analytical thinking

Documentation skills

Communication skills

HIPAA compliance

Education

RN license

InterQual/Milliman criteria knowledge

Payer regulations knowledge

Job description

Quorum Health Corporation is seeking a remote Utilization Review Specialist (Case Manager) to support admission decisions and appeals. The role requires an RN license and strong knowledge of criteria sets to support clinical appeals and quality reviews.

Responsibilities include reviewing patient records, coordinating appeals, and ensuring timely documentation and reporting while coordinating with payer and hospital staff. This is a remote, full-time position with state residency eligibility.