Remote RN Case Manager: Utilization Review Expert

Jobgether; Clayton (NM); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Remote work

Professional development support

Paid time off

Job summary

Jobgether is partnering with a healthcare organization seeking an experienced RN to lead utilization reviews remotely. The role focuses on admission and concurrent reviews, medical necessity assessment, and drafting evidence-based appeal letters.

Collaboration with physicians, medical directors, and payer representatives is essential to improve outcomes and compliance. The ideal candidate brings 5+ years of acute care nursing and 5–7 years in case management or utilization review, with strong

Qualifications

• Current, active registered nurse (RN) license issued by a U.S. state is required.
• At least five years of clinical nursing experience in an acute care setting is required.
• Five to seven years of experience in case management, discharge planning, utilization review, or a closely related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards governing case management activities.
• Familiarity with established clinical decision-support criteria, such as InterQual and Milliman & Robertson (MCG care guidelines), is preferred.
• Demonstrated ability to review complex clinical records, assess medical necessity, evaluate treatment plans, and make sound decisions.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze patient records, payer requirements, and policies to ensure criteria are met.
• Identify potential reimbursement denials and develop strategies to prevent recurring issues.
• Review documentation to determine next steps, including appeals as needed.
• Coordinate first-, second-, and third-level appeals with deadlines.
• Draft professional appeal letters with clinical evidence and policies.
• Monitor appeal timelines and outcomes with internal teams.
• Maintain accurate documentation of reviews, denials, and outcomes in databases.

Skills

RN license

Clinical nursing

Utilization review

Analytical thinking

Written communication

Verbal communication

Independent work

Tools

InterQual

MCG guidelines

Job description

Jobgether is partnering with a healthcare organization seeking an experienced RN to lead utilization reviews remotely. The role focuses on admission and concurrent reviews, medical necessity assessment, and drafting evidence-based appeal letters.

Collaboration with physicians, medical directors, and payer representatives is essential to improve outcomes and compliance. The ideal candidate brings 5+ years of acute care nursing and 5–7 years in case management or utilization review, with strong