Remote Case Manager: Utilization Review Specialist

Jobgether; Nevada; Remote; USD 90,000 - 120,000; Full time

Job summary

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote position based in the United States. You will oversee admission and concurrent utilization reviews, identify potential denials, and coordinate appeals to support patient care and financial performance.

Apply clinical nursing expertise to evaluate medical records, assess medical necessity, and develop evidence-based appeals. Collaborate with physicians, case managers, and payer representatives to resolve complex

Qualifications

• At least five years of clinical nursing experience in an acute care setting is required.
• Five to seven years of experience in case management, discharge planning, utilization review, or a closely related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards governing case management activities.
• Familiarity with established clinical decision-support criteria, such as InterQual and Milliman & Robertson (MCG), is preferred.
• Demonstrated ability to review complex clinical records, assess medical necessity, evaluate treatment plans, and make sound decisions regarding patient care and discharge planning.
• Experience preparing and coordinating clinical or administrative appeals, including supporting documentation, is highly desirable.
• Excellent written and verbal communication and interpersonal skills.
• Ability to interpret and extract relevant information from complex medical records.
• Proficiency in data entry, recordkeeping, database management, and maintaining accurate documentation.
• Strong organizational and time-management skills for multiple cases and deadlines.
• Applicants must live in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Tennessee, Texas, Utah, or Wyoming to be eligible for this remote position.
• Remote work: Full-time remote work arrangement, subject to eligible-state residency requirements.
• Opportunity to apply nursing expertise to utilization management, medical necessity reviews, denial prevention, and patient care coordination.
• Work closely with clinical teams, physicians, medical directors, case managers, and payer representatives.
• Process improvement: contribute to quality improvement initiatives, appeals performance, and more effective workflows.
• Note about healthcare coverage and benefits needing verification during recruitment.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Identify potential reimbursement denials and develop prevention strategies.
• Review clinical documentation and claim histories to determine next steps.
• Coordinate first-, second-, and third-level appeals with deadlines.
• Draft appeal letters supported by clinical evidence, medical records, payer policies, and regulations.
• Maintain accurate documentation of reviews, appeals, and outcomes in databases and billing systems.
• Collaborate with physicians, nurses, case managers, medical directors, and payer representatives.
• Support quality improvement initiatives and compliance with HIPAA.

Skills

Clinical nursing experience

Utilization review

Case management

Appeals coordination

Regulatory knowledge

HIPAA compliance

Excellent communication

Education

RN license

BSN (optional)

Tools

InterQual

Milliman & Robertson (MCG)

MCG guidelines

Job description

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote position based in the United States. You will oversee admission and concurrent utilization reviews, identify potential denials, and coordinate appeals to support patient care and financial performance.

Apply clinical nursing expertise to evaluate medical records, assess medical necessity, and develop evidence-based appeals. Collaborate with physicians, case managers, and payer representatives to resolve complex