Remote Case Manager - Utilization Review Specialist

Jobgether; Tennessee; Remote; USD 80.000 - 110.000; Vollzeit

Zusammenfassung

Jobgether is seeking a Case Manager – Utilization Review Specialist for a fully remote role in the United States. You will evaluate medical records for necessity, coordinate administrative and clinical appeals, and work with physicians, medical directors, and payer representatives to improve review outcomes.

Applicants should have strong nursing experience in acute care and solid knowledge of payer policies and regulatory standards.

Qualifikationen

• Minimum 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 a related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, and regulatory standards.

Aufgaben

• Oversee admission and concurrent utilization reviews for medical necessity and length of stay.
• Identify potential reimbursement denials and develop strategies to prevent recurring issues.
• Coordinate first-, second-, and third-level appeals with physician advisors and medical directors.
• Draft professional appeal letters supported by clinical evidence and payer policies.
• Maintain accurate documentation of reviews, appeals, and outcomes in databases and billing systems.

Kenntnisse

Clinical nursing experience

Utilization management

Medical records review

Appeals coordination

HIPAA compliance

Communication skills

Ausbildung

RN licensure (US)

Bachelor's degree in Nursing

Jobbeschreibung

Jobgether is seeking a Case Manager – Utilization Review Specialist for a fully remote role in the United States. You will evaluate medical records for necessity, coordinate administrative and clinical appeals, and work with physicians, medical directors, and payer representatives to improve review outcomes.

Applicants should have strong nursing experience in acute care and solid knowledge of payer policies and regulatory standards.