Remote RN Case Manager: Utilization & Appeals Expert

Jobgether; Central City (KY); Remoto; USD 70.000 - 100.000; Tempo pieno

Vantaggi offerti da questo lavoro

Remote work

Clinical impact

Professional collaboration

Process improvement

Descrizione del lavoro

Partner Company is seeking an experienced Registered Nurse for a fully remote Case Manager – Utilization Review Specialist position in the United States. The role focuses on admission reviews, concurrent reviews, and developing evidence-based appeals to support appropriate patient care and financial performance.

You will analyze clinical records, determine medical necessity, and collaborate with physicians, medical directors, and payer representatives to resolve complex cases and improve review

Competenze

• Active RN license in the United States.
• At least five years of clinical nursing experience in acute care.
• Five to seven years in case management, discharge planning, or utilization review preferred.
• Strong knowledge of utilization management practices and payer requirements.
• Familiarity with InterQual or MCG guidelines preferred.

Mansioni

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Review medical records and payer policies to determine admission appropriateness.
• Identify potential denials and develop prevention strategies via workflow improvements.
• Coordinate appeals across multiple levels with complete documentation.
• Draft professional appeal letters supported by clinical evidence and policies.
• Monitor appeal timelines and outcomes, collaborating with departments to resolve issues.
• Maintain accurate documentation in databases and billing systems.
• Build relationships with payer utilization management and appeals teams.
• Support quality assurance and process improvement initiatives.

Conoscenze

Clinical nursing experience

Analytical thinking

Communication skills

Regulatory knowledge

Formazione

Registered nurse license (RN)

Strumenti

InterQual

MCG care guidelines

Descrizione del lavoro

Partner Company is seeking an experienced Registered Nurse for a fully remote Case Manager – Utilization Review Specialist position in the United States. The role focuses on admission reviews, concurrent reviews, and developing evidence-based appeals to support appropriate patient care and financial performance.

You will analyze clinical records, determine medical necessity, and collaborate with physicians, medical directors, and payer representatives to resolve complex cases and improve review