Remote Case Manager: Utilization Review Specialist (RN)

Jobgether; Salem (OR); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Remote work

Professional collaboration

Quality improvement initiatives

Paid time off or benefits not stated

Job summary

Jobgether, on behalf of a partner company, seeks an experienced Case Manager – Utilization Review Specialist to oversee admission and concurrent reviews remotely in the United States. You will evaluate medical records for medical necessity, coordinate appeals, and collaborate with clinicians and payers to improve outcomes and financial performance.

You will apply clinical nursing expertise, support quality improvements, and work independently within HIPAA-compliant processes while maintaining

Qualifications

• Active RN license in the United States.
• Minimum five years nursing in an acute care setting.
• Five to seven years in case management, discharge planning, utilization review, or related discipline.
• Strong knowledge of utilization management practices, payer requirements, and regulatory standards.
• Familiarity with InterQual and MCG/decision-support criteria preferred.
• Excellent written and verbal communication skills.

Responsibilities

• Conduct admission and concurrent utilization reviews for medical necessity and LOS.
• Analyze patient records to ensure adherence to criteria and payer policies.
• Identify potential reimbursement denials and develop prevention strategies.
• Coordinate first-, second-, and third-level appeals with timely submissions.
• Draft appeal letters with clinical evidence and documentation.
• Coordinate reviews with physicians, advisors, and payer representatives.
• Monitor appeal timelines and outcomes; document in systems.

Skills

RN license

Nursing in acute care

Utilization review

Analytical thinking

Written communication

Verbal communication

Time management

Data entry/recordkeeping

Tools

InterQual

MCG care guidelines

Job description

Jobgether, on behalf of a partner company, seeks an experienced Case Manager – Utilization Review Specialist to oversee admission and concurrent reviews remotely in the United States. You will evaluate medical records for medical necessity, coordinate appeals, and collaborate with clinicians and payers to improve outcomes and financial performance.

You will apply clinical nursing expertise, support quality improvements, and work independently within HIPAA-compliant processes while maintaining