Remote RN Case Manager: Utilization Review & Appeals

Jobgether; Wyoming (MI); Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote work

Clinical impact

Professional collaboration

Process improvement

Job summary

Jobgether, on behalf of a partner company, is seeking a Case Manager – Utilization Review Specialist based in the United States. This remote role oversees admission and concurrent reviews, assesses medical necessity, and coordinates appeals with physicians, payers, and case managers to support appropriate patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, manage denials, and ensure compliance with HIPAA and payer requirements, working

Qualifications

• Active RN license in a U.S. state is required.
• 5+ years of clinical nursing in acute care.
• 5–7 years in case management, discharge planning, utilization review, or related field preferred.
• Knowledge of utilization management, payer requirements, and regulatory standards.
• Familiarity with InterQual / MCG guidelines is preferred.
• Ability to review complex records and determine medical necessity for care and discharge planning.
• Experience preparing and coordinating clinical/administrative appeals with supporting documentation.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity.
• Analyze records and policies to ensure compliance with criteria and regulations.
• Identify denials and develop strategies to prevent recurrence via workflow improvements.
• Review documentation to determine next steps and appeals needed.
• Coordinate first- to third-level appeals with complete documentation.
• Draft professional appeal letters with evidence and payer policies.

Skills

RN license

Clinical nursing

Case management

InterQual

MCG care guidelines

Communication

Documentation

Time management

Analytical thinking

Tools

EHR systems

Job description

Jobgether, on behalf of a partner company, is seeking a Case Manager – Utilization Review Specialist based in the United States. This remote role oversees admission and concurrent reviews, assesses medical necessity, and coordinates appeals with physicians, payers, and case managers to support appropriate patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, manage denials, and ensure compliance with HIPAA and payer requirements, working