Remote RN Utilization Review & Appeals Specialist

Jobgether; Santa Fe (NM); Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

Remote work

Paid time off

Health benefits

Job summary

Jobgether is partnering with a healthcare organization to hire a Case Manager - Utilization Review Specialist for a full-time remote role based in the United States. You will oversee admission and concurrent reviews, assess medical necessity, and coordinate appeals to support appropriate 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 initiatives in

Qualifications

• Active RN license in a U.S. state.
• Minimum five years of clinical nursing in acute care.
• Five to seven years in case management, discharge planning or utilization review preferred.
• Strong knowledge of utilization management practices and payer policies.
• Familiarity with InterQual and Milliman & Robertson (MCG) guidelines favored.

Responsibilities

• Perform admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze medical records and payer requirements to ensure criteria are met.
• Identify potential denials and propose workflow improvements.
• Coordinate first-, second-, and third-level appeals with documentation.
• Draft clear appeal letters with supporting evidence and regulations.
• Collaborate with physicians, nurses, and payer representatives to resolve cases.
• Maintain accurate documentation in databases and billing systems.
• Support utilization review committees and quality improvement activities.

Skills

RN license

Clinical nursing experience

Utilization review

Communication

Independent work

Tools

InterQual

MCG guidelines

Job description

Jobgether is partnering with a healthcare organization to hire a Case Manager - Utilization Review Specialist for a full-time remote role based in the United States. You will oversee admission and concurrent reviews, assess medical necessity, and coordinate appeals to support appropriate 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 initiatives in