Remote Case Manager: Utilization Review Expert

Jobgether; Milton (MA); A distancia; USD 90.000 - 120.000; Jornada completa

Descripción de la vacante

Jobgether represents a partner company seeking a Case Manager – Utilization Review Specialist based in the United States. In this remote role, you will oversee admission and concurrent utilization reviews, assess medical necessity, and coordinate appeals to support patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, collaborate with physicians and payer representatives, maintain documentation, and participate in quality improvement activities.

Formación

• 5+ years of clinical nursing experience in an acute care setting.
• 5–7 years of experience in case management, discharge planning, utilization review, or related healthcare discipline.
• Strong knowledge of utilization management practices, payer requirements, and regulatory standards.
• Familiarity with InterQual and Milliman & Robertson (MCG) guidelines is preferred.
• Ability to review complex clinical records and support clinical evidence in appeals.

Responsabilidades

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Identify potential reimbursement denials and develop prevention strategies through workflow improvements.
• Coordinate first-, second-, and third-level appeals with complete documentation.
• Maintain accurate documentation of reviews, denials, appeals, and outcomes in databases and billing systems.
• Collaborate with physicians, nurses, case managers, medical directors, and payer representatives to resolve complex cases.
• Support quality improvement initiatives, appeals audits, and utilization review committees.
• Protect patient confidentiality per HIPAA and other privacy regulations.
• Interpret and extract relevant information from complex medical records to support decisions.

Conocimientos

Clinical nursing

Utilization management

Case management

Medical record review

Regulatory compliance

Educación

RN license

Descripción del empleo

Jobgether represents a partner company seeking a Case Manager – Utilization Review Specialist based in the United States. In this remote role, you will oversee admission and concurrent utilization reviews, assess medical necessity, and coordinate appeals to support patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, collaborate with physicians and payer representatives, maintain documentation, and participate in quality improvement activities.