Remote RN Case Manager – Utilization & Appeals

Quorum Health Corporation; Nashville (TN); Remote; USD 85,000 - 110,000; Full time

Job summary

Quorum Health Corporation is seeking an experienced Utilization Review Specialist (Case Manager) to join our remote team. The role focuses on admission and concurrent reviews to prevent denials and improve workflow through root-cause analysis.

You must have a current RN license and extensive experience in case management, discharge planning, and utilization review, with knowledge of InterQual criteria and payer regulations. HIPAA compliance is essential.

Qualifications

• Significant healthcare experience required, including five years as a clinical nurse in an acute care setting.
• At least five to seven years in case management, discharge planning, and/or utilization review preferred.
• Knowledge of regulatory and payer requirements for Case Management activities.
• Ability to evaluate discharge planning for complex cases and use established criteria to support appeals.

Responsibilities

• Analyze patient records to determine admission needs and length of stay according to government and payer policies.
• Assess standards from insurance, government, and accrediting bodies for admissions and care.
• Approve admissions or refer to utilization review committee when criteria are not met.
• Coordinate first to third level appeals and assign reviews to physician advisors and medical directors.
• Ensure documentation of denials and maintain data for reporting and QA activities.
• Support timely appeals and collaborate with other departments to resolve issues.

Skills

RN license

Case management

Discharge planning

Utilization review

HIPAA compliance

Regulatory knowledge

Education

Nursing degree (RN)

Tools

InterQual Criteria

Milliman & Robertson Criteria

Job description

Quorum Health Corporation is seeking an experienced Utilization Review Specialist (Case Manager) to join our remote team. The role focuses on admission and concurrent reviews to prevent denials and improve workflow through root-cause analysis.

You must have a current RN license and extensive experience in case management, discharge planning, and utilization review, with knowledge of InterQual criteria and payer regulations. HIPAA compliance is essential.