Remote Case Manager: Utilization Review & Appeals Expert

Jobgether; Texas; A distancia; USD 75.000 - 95.000; Jornada completa

Descripción de la vacante

Jobgether is seeking a Case Manager – Utilization Review Specialist based in the United States. This fully remote role focuses on admission and concurrent reviews, medical necessity, and appeal coordination to improve reimbursement outcomes and compliance with clinical criteria.

Qualified applicants will have 5+ years of clinical nursing and 5–7 years in case management or utilization review, with strong knowledge of payer policies and regulatory standards.

Formación

• Five years of clinical nursing experience in an acute care setting.
• Five to seven years of experience in case management, discharge planning, utilization review, or related healthcare discipline.
• Strong knowledge of utilization management, payer requirements, and regulatory standards.
• Familiarity with InterQual and Milliman & Robertson guidelines.

Responsabilidades

• Conduct admission and concurrent utilization reviews to assess medical necessity and LOS.
• Identify potential reimbursement denials and develop strategies to prevent them.
• Coordinate first-, second-, and third-level appeals with physician advisors and payers.
• Draft professional appeal letters with supporting clinical evidence and policies.
• Maintain documentation of reviews, appeals, and outcomes in databases.
• Collaborate with clinicians and payer representatives to resolve cases.
• Support quality improvement and utilization review committees.

Conocimientos

Clinical nursing

Case management

Discharge planning

Utilization review

Payer requirements

Regulatory standards

Communication skills

HIPAA compliance

Educación

Registered Nurse license

Herramientas

InterQual

MCG guidelines

Descripción del empleo

Jobgether is seeking a Case Manager – Utilization Review Specialist based in the United States. This fully remote role focuses on admission and concurrent reviews, medical necessity, and appeal coordination to improve reimbursement outcomes and compliance with clinical criteria.

Qualified applicants will have 5+ years of clinical nursing and 5–7 years in case management or utilization review, with strong knowledge of payer policies and regulatory standards.