Remote RN: Utilization Review Case Manager

Jobgether; Accident (MD); Remote; USD 85,000 - 120,000; Full time

Benefits offered by this job

Remote work

Job summary

Jobgether seeks a Case Manager – Utilization Review Specialist to oversee admission and ongoing utilization reviews remotely for the United States. The role focuses on medical necessity assessment, documenting reviews, and coordinating timely appeals to support patient care and financial performance.

You will work with physicians, medical directors, and payer representatives, applying clinical judgment and analytical thinking to resolve complex cases and drive quality improvement in utilization

Qualifications

• Active RN license in the United States.
• At least five years of clinical nursing experience in an acute care setting.
• Five to seven years in case management or related healthcare discipline preferred.
• Strong knowledge of utilization management, payer requirements and regulatory standards.
• Familiarity with InterQual or MCG care guidelines preferred.
• Excellent analytical, written and verbal communication skills.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity.
• Analyze medical records, payer policies, and regulations to confirm criteria.
• Identify denial risks and improve utilization review workflows.
• Coordinate first-, second-, and third-level appeals with documentation.
• Draft professional appeal letters with supporting evidence.

Skills

RN license

Nursing experience

Case management

Communication

Analytical thinking

HIPAA compliance

InterQual knowledge

Tools

InterQual

Job description

Jobgether seeks a Case Manager – Utilization Review Specialist to oversee admission and ongoing utilization reviews remotely for the United States. The role focuses on medical necessity assessment, documenting reviews, and coordinating timely appeals to support patient care and financial performance.

You will work with physicians, medical directors, and payer representatives, applying clinical judgment and analytical thinking to resolve complex cases and drive quality improvement in utilization