Remote RN Case Manager: Utilization Review Specialist

Jobgether; Utah; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote work

Paid time off

Retirement plans

Professional development

Healthcare coverage

Job summary

Jobgether seeks an experienced Case Manager – Utilization Review Specialist for a remote role in the United States. You will oversee admission and concurrent reviews, analyze records for medical necessity, and coordinate multi-level appeals to support appropriate patient care and financial performance.

You will apply nursing expertise to evaluate clinical records, determine treatment necessity, and help improve review processes.

Qualifications

• Current, active RN license issued by a U.S. state is required.
• 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 related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, and regulatory standards.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze medical records and payer policies to determine appropriateness of admissions and treatments.
• Identify potential reimbursement denials and develop mitigation strategies through workflow improvements.
• Coordinate first-, second-, and third-level appeals with complete supporting documentation.
• Draft professional appeal letters with clinical evidence and applicable regulations.
• Monitor appeal timelines and outcomes, collaborating with internal departments.

Skills

RN license

Clinical nursing experience

Utilization review

Discharge planning

Analytical thinking

Communication skills

Regulatory knowledge

Education

Registered Nurse (RN) licensure

Tools

InterQual

Milliman & Robertson / MCG guidelines

Job description

Jobgether seeks an experienced Case Manager – Utilization Review Specialist for a remote role in the United States. You will oversee admission and concurrent reviews, analyze records for medical necessity, and coordinate multi-level appeals to support appropriate patient care and financial performance.

You will apply nursing expertise to evaluate clinical records, determine treatment necessity, and help improve review processes.