Remote RN: Utilization Review & Case Management Specialist

Quorum Health Corporate; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

Quorum Health Corporate is seeking a remote Utilization Review Specialist with a registered nurse background to manage admission decisions and concurrent reviews, ensuring compliance with payer and regulatory standards.

Responsibilities include coordinating appeals, documenting denials, and collaborating with health-care staff to resolve issues efficiently. The role emphasizes data abstraction, workflow improvement, and adherence to HIPAA requirements.

Qualifications

• Current state-issued RN license.
• Knowledge of InterQual and Milliman criteria, and payer regulations related to utilization review is preferred.

Responsibilities

• Analyze patient records to assess admission, treatment, and length of stay per payer and regulatory standards.
• Review admission applications and approve or refer to utilization review for escalation.
• Abstract data from records and maintain statistics for reporting.
• Coordinate appeals across first to third level with physician advisors and management.
• Ensure proper documentation of denials and track outcomes for reporting.

Skills

RN license

Case management

Utilization review

Discharge planning

Job description

Quorum Health Corporate is seeking a remote Utilization Review Specialist with a registered nurse background to manage admission decisions and concurrent reviews, ensuring compliance with payer and regulatory standards.

Responsibilities include coordinating appeals, documenting denials, and collaborating with health-care staff to resolve issues efficiently. The role emphasizes data abstraction, workflow improvement, and adherence to HIPAA requirements.