Remote RN: Utilization Review & Appeals Expert

Jobgether; Oregon; Hybrid; USD 75,000 - 110,000; Full time

Benefits offered by this job

Remote work

Clinical impact

Professional collaboration

Job summary

Jobgether seeks a Case Manager - Utilization Review Specialist to join a remote healthcare team in the United States. You will conduct admissions, concurrent reviews, and appeals, applying clinical nursing judgment to determine medical necessity and support appropriate care and reimbursement.

You will collaborate with physicians, case managers, and payer representatives to resolve complex cases, improve utilization review processes, and ensure compliance with HIPAA and payer policies.

Qualifications

• Current, active RN license in the United States.
• At least five years' acute care nursing experience.
• Five to seven years in case management or related field.
• Strong knowledge of utilization management practices and payer policies.
• Experience coordinating clinical or administrative appeals.

Responsibilities

• Conduct admissions and concurrent utilization reviews to assess medical necessity.
• Identify potential reimbursement denials and develop prevention strategies.
• Coordinate first-, second-, and third-level appeals with deadlines.
• Draft appeal letters with clinical evidence and payer policies.
• Monitor appeal timelines and outcomes, collaborating with stakeholders.
• Maintain accurate documentation in databases and billing systems.
• Collaborate with physicians, nurses, and payer representatives to resolve cases.

Skills

RN license

Clinical nursing experience

Utilization review

Appeals coordination

Communication skills

Analytical thinking

Tools

InterQual

Milliman & Robertson guidelines

Job description

Jobgether seeks a Case Manager - Utilization Review Specialist to join a remote healthcare team in the United States. You will conduct admissions, concurrent reviews, and appeals, applying clinical nursing judgment to determine medical necessity and support appropriate care and reimbursement.

You will collaborate with physicians, case managers, and payer representatives to resolve complex cases, improve utilization review processes, and ensure compliance with HIPAA and payer policies.