Remote RN Utilization Review Case Manager

Jobgether; Kentucky; Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Remote work

Clinical impact

Professional collaboration

Process improvement

Job summary

Jobgether invites applications for a remote Case Manager – Utilization Review Specialist based in the United States. You will lead admission and concurrent reviews, assess medical necessity, and develop evidence-based appeals while collaborating with physicians, case managers, and payer representatives.

You will leverage clinical nursing expertise to evaluate records, ensure compliance, and support timely appeal resolutions in a fast-paced environment.

Qualifications

• Current, active RN license issued by a U.S. state.
• 5+ years of clinical nursing experience in an acute care setting.
• 5–7 years of experience in case management, discharge planning, utilization review, or related healthcare discipline preferred.
• Strong knowledge of UM practices, payer requirements, reimbursement policies, and regulatory standards.
• Familiarity with InterQual and Milliman & Robertson (MCG) guidelines preferred.
• Ability to review complex clinical records, assess medical necessity, and make discharge planning decisions.
• Experience preparing and coordinating clinical or administrative appeals with supporting documentation.
• Strong written and verbal communication skills for appeals and reports.
• Ability to work independently in a remote environment.
• Residency restriction: must live in AR, CA, KY, MA, NV, NM, OR, TN, TX, UT, or WY.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze patient records, payer requirements, and accreditation standards to determine criteria.
• Identify potential reimbursement denials and develop prevention strategies via workflow improvements.
• Review documentation to determine appeals needs and coordinate first–third level appeals.
• Draft appeal letters supported by evidence, records, and policies.
• Assign reviews to physician advisors when needed and monitor outcomes.
• Maintain documentation in databases and billing systems; ensure deadlines are met.
• Collaborate with clinicians and payer representatives to resolve issues.
• Protect patient confidentiality per HIPAA and related privacy requirements.

Skills

RN License US

Utilization Review

Clinical judgement

Communication

Analytical thinking

Tools

InterQual

MCG guidelines

Job description

Jobgether invites applications for a remote Case Manager – Utilization Review Specialist based in the United States. You will lead admission and concurrent reviews, assess medical necessity, and develop evidence-based appeals while collaborating with physicians, case managers, and payer representatives.

You will leverage clinical nursing expertise to evaluate records, ensure compliance, and support timely appeal resolutions in a fast-paced environment.