Remote RN: Utilization Review & Appeals Specialist

Jobgether; New Mexico; Remote; USD 90,000 - 110,000; Full time

Benefits offered by this job

Remote work

Clinical impact

Professional collaboration

Process improvements

Job summary

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote role based in the United States. You will conduct admission and concurrent reviews, assess medical necessity, and coordinate appeals to support patient care and payer requirements.

Work with physicians, nurses, and payer representatives to resolve complex cases, improve utilization review workflows, and ensure compliance with HIPAA and applicable regulations.

Qualifications

• Current, active RN license in a U.S. state.
• 5+ years of acute care nursing experience.
• 5–7 years in case management, discharge planning, utilization review, or related healthcare discipline.
• Knowledge of utilization management practices, payer requirements, reimbursement policies and regulatory standards.
• Familiarity with InterQual and MCG guidelines.
• Strong communication and analytical skills.

Responsibilities

• Perform admission and concurrent utilization reviews for medical necessity and length of stay.
• Identify potential denials and develop strategies to prevent recurrence.
• Draft professional appeal letters supported by clinical evidence.
• Coordinate first-, second-, and third-level appeals with deadlines.
• Maintain accurate documentation in databases and billing systems.
• Collaborate with physicians, nurses, case managers, and payer representatives.
• Monitor appeal timelines and outcomes; drive process improvements.

Skills

RN license

Clinical nursing

Case management

Utilization review

Regulatory knowledge

Written communication

Analytical thinking

Job description

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote role based in the United States. You will conduct admission and concurrent reviews, assess medical necessity, and coordinate appeals to support patient care and payer requirements.

Work with physicians, nurses, and payer representatives to resolve complex cases, improve utilization review workflows, and ensure compliance with HIPAA and applicable regulations.