Remote RN Utilization Review Case Manager

Jobgether; Lexington (KY); Remote; USD 90,000 - 110,000; Full time

Benefits offered by this job

Remote work: Full-time remote role

Professional collaboration with care/p

Quality improvement initiatives

HIPAA-compliant processes

Job summary

Jobgether is seeking an experienced Case Manager – Utilization Review Specialist for a remote role in the United States. You will apply clinical nursing expertise to evaluate records, assess medical necessity, and develop evidence-based appeals, collaborating with physicians, medical directors, and payers to improve reimbursement outcomes and compliance.

You will conduct admissions and concurrent reviews, coordinate multi-level appeals, and monitor outcomes while maintaining HIPAA-compliant

Qualifications

• Current, active RN license issued by a U.S. state.
• At least five years of clinical nursing experience in acute care.
• Five to seven years in case management, discharge planning, utilization review, or related healthcare discipline.
• Knowledge of utilization management practices, payer requirements, and regulatory standards.
• Familiarity with InterQual/MCG guidelines is a plus.
• Ability to review complex medical records and support clinical decisions with evidence.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity.
• Identify potential reimbursement denials and develop prevention strategies through workflow improvements.
• Coordinate first-, second-, and third-level appeals with complete supporting documentation.
• Draft clear appeal letters with clinical evidence, records, and payer policies.
• Monitor appeal timelines and outcomes while collaborating with internal departments.
• Maintain accurate documentation of denials, reviews, and appeal activities in databases.

Skills

RN license (US)

Clinical nursing experience

Case management

Utilization review

Analytical thinking

Communication skills

Job description

Jobgether is seeking an experienced Case Manager – Utilization Review Specialist for a remote role in the United States. You will apply clinical nursing expertise to evaluate records, assess medical necessity, and develop evidence-based appeals, collaborating with physicians, medical directors, and payers to improve reimbursement outcomes and compliance.

You will conduct admissions and concurrent reviews, coordinate multi-level appeals, and monitor outcomes while maintaining HIPAA-compliant