Remote RN: Utilization Review Case Manager

Jobgether; Oklahoma City (OK); Remote; USD 90,000 - 125,000; Full time

Job summary

Partner Company in the United States is seeking a Case Manager – Utilization Review Specialist to oversee admission and concurrent reviews, assess medical necessity, and coordinate appeals in a remote role.

You will apply clinical nursing expertise, analyze records, draft appeal letters, and collaborate with physicians, case managers, and payer representatives to improve utilization review processes and outcomes.

Qualifications

• Current active RN license required.
• At least five years of clinical nursing experience in acute care.
• Five to seven years in case management, discharge planning, utilization review, or related field preferred.
• Strong knowledge of UM practices, payer requirements, and regulatory standards.
• Familiarity with InterQual and MCG criteria.
• Ability to review complex records and assess medical necessity.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze patient records against payer policies and criteria.
• Identify denial risks and develop strategies to prevent recurrences.
• Coordinate first-, second-, and third-level appeals with documentation.
• Draft professional appeal letters with supporting evidence and policies.
• Assign reviews to physician advisors when needed.
• Monitor appeal timelines and outcomes; liaise with stakeholders.
• Maintain accurate documentation in databases and billing systems.
• Support UR committees and quality assurance activities.

Skills

RN license

Clinical nursing experience

Case management experience

Analytical thinking

Written communication

HIPAA compliance

Independent work

Education

RN license

Tools

InterQual

MCG care guidelines

Job description

Partner Company in the United States is seeking a Case Manager – Utilization Review Specialist to oversee admission and concurrent reviews, assess medical necessity, and coordinate appeals in a remote role.

You will apply clinical nursing expertise, analyze records, draft appeal letters, and collaborate with physicians, case managers, and payer representatives to improve utilization review processes and outcomes.