Remote Case Manager — Utilization Review Expert

Jobgether; Sacramento (CA); Remote; USD 90,000 - 120,000; Full time

Job summary

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote US-based position. You will oversee admission and concurrent reviews, analyze medical records for medical necessity, and coordinate first-, second-, and third-level appeals with physician advisors and payer representatives.

Join a healthcare team focused on improving utilization management, reimbursement outcomes, and compliance with clinical and payer requirements while maintaining HIPAA privacy and high-quality

Qualifications

• At least five years of clinical nursing experience in an acute care setting.
• Five to seven years in case management, discharge planning, utilization review, or related healthcare discipline preferred.
• Strong knowledge of utilization management practices, payer requirements, and regulatory standards.
• Experience reviewing complex medical records and determining medical necessity.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity.
• Identify potential reimbursement denials and develop prevention strategies through workflow improvements.
• Coordinate first-, second-, and third-level appeals with physician advisors and payer representatives.
• Draft professional appeal letters supported by clinical evidence and documentation.
• Maintain accurate documentation of reviews, appeals, and outcomes in databases and billing systems.
• Present appeal findings and utilization data to committees and stakeholders.

Skills

Utilization management

Payer requirements

Regulatory standards

Clinical decision-making

Written communication

Collaborative skills

Education

RN license

BSN

Tools

InterQual

MCG guidelines

HIPAA systems

Job description

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote US-based position. You will oversee admission and concurrent reviews, analyze medical records for medical necessity, and coordinate first-, second-, and third-level appeals with physician advisors and payer representatives.

Join a healthcare team focused on improving utilization management, reimbursement outcomes, and compliance with clinical and payer requirements while maintaining HIPAA privacy and high-quality