Remote Nurse Case Manager: Utilization Review

Jobgether; Heber (UT); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Remote work

Professional collaboration

Quality improvement initiatives

Job summary

Jobgether, on behalf of a partner company, is seeking a Case Manager – Utilization Review Specialist for a remote US-based position. The role focuses on admission and concurrent reviews, denials prevention, and appeals support, leveraging clinical nursing expertise in a collaborative environment.

The ideal candidate has RN licensure and 5+ years in clinical nursing and case management, with strong knowledge of utilization management, payer policies, and regulatory standards.

Qualifications

• Current, active RN license issued by a U.S. state is required.
• 5+ years of clinical nursing experience in acute care is required.
• 5–7 years of experience in case management, discharge planning, utilization review, or related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards.
• Familiarity with InterQual and Milliman & Robertson (MCG) guidelines is preferred.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze patient records and payer requirements to determine criteria compliance.
• Identify reimbursement denials and develop prevention strategies via workflow improvements.
• Review documentation to determine next steps, including appeals.
• Coordinate first-, second-, and third-level appeals with supporting documentation.
• Draft appeal letters with clinical evidence and payer policies.
• Assign reviews to physician advisors when needed.
• Monitor appeal timelines and outcomes; collaborate with internal departments.
• Maintain documentation in databases and billing systems.
• Establish relationships with payer utilization management and appeals teams.
• Collaborate with case managers and physicians to resolve challenges.
• Track appeal volumes and request resources as needed.
• Prepare and present appeal findings and performance reports.
• Support audits and quality improvement activities.

Skills

RN license

acute care

case management

utilization review

regulatory standards

clinical documentation

communication

data management

HIPAA

Tools

InterQual

Milliman & Robertson (MCG)

Job description

Jobgether, on behalf of a partner company, is seeking a Case Manager – Utilization Review Specialist for a remote US-based position. The role focuses on admission and concurrent reviews, denials prevention, and appeals support, leveraging clinical nursing expertise in a collaborative environment.

The ideal candidate has RN licensure and 5+ years in clinical nursing and case management, with strong knowledge of utilization management, payer policies, and regulatory standards.