Remote RN: Utilization Review & Appeals Specialist

Jobgether; Little Rock (AR); Remote; USD 85,000 - 105,000; Full time

Benefits offered by this job

Remote work

Professional development support

Paid time off

Retirement plans

Job summary

Jobgether, in partnership with a healthcare organization, seeks an experienced Case Manager – Utilization Review Specialist for a fully remote role in the United States. This position focuses on admission and concurrent reviews, medical necessity assessment, and coordination of payer appeals to support patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, collaborate with physicians and payer representatives, and contribute to quality improvement

Qualifications

• Active RN license in a U.S. state is required.
• 5+ years nursing experience in acute care.
• 5–7 years in case management, discharge planning or utilization review preferred.
• Knowledge of payer requirements and regulatory standards.
• Experience preparing and coordinating clinical or administrative appeals.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity.
• Analyze patient records and payer policies to ensure criteria compliance.
• Identify denial risks and develop prevention strategies via workflow improvements.
• Review documentation to determine next steps, including appeals.
• Coordinate first to third level appeals with complete supporting docs.
• Draft appeal letters with clinical evidence and relevant regulations.
• Assign reviews to physician advisors when needed.
• Monitor appeal timelines and outcomes with internal teams.
• Maintain accurate denial and review records in databases and billing systems.
• Develop relationships with payer utilization management and appeals depts.

Skills

RN license

Clinical nursing

Case management

Utilization review

Medical necessity assessment

Appeals coordination

Documentation

Communication skills

Analytical thinking

Time management

Tools

EMR systems

Billing databases

InterQual criteria

MCG guidelines

Job description

Jobgether, in partnership with a healthcare organization, seeks an experienced Case Manager – Utilization Review Specialist for a fully remote role in the United States. This position focuses on admission and concurrent reviews, medical necessity assessment, and coordination of payer appeals to support patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, collaborate with physicians and payer representatives, and contribute to quality improvement