Remote RN: Utilization Review & Case Manager

Jobgether; United States; Remote; USD 85.000 - 120.000; Vollzeit

Benefits dieser Stelle

Remote work

Zusammenfassung

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote United States position. You will use your nursing expertise to evaluate medical records, assess medical necessity, and manage appeals to support patient care and financial performance.

Collaborate with physicians, medical directors, and payer representatives to resolve complex cases, improve review processes, and ensure compliance with payer policies and clinical criteria.

Qualifikationen

• Active RN license in a U.S. state.
• 5+ years of clinical nursing experience in acute care.
• 5–7 years in case management, discharge planning, utilization review, or related field.

Aufgaben

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Analyze medical records, payer requirements, and regulatory standards for eligibility.
• Identify potential reimbursement denials and develop strategies to prevent them.
• Review documentation to determine appropriate next steps and appeals needs.
• Coordinate first-, second-, and third-level appeals with complete documentation.
• Draft professional appeal letters with clinical evidence and payer policies.
• Assign reviews to physician advisors when needed.
• Monitor appeal timelines and outcomes with internal teams.
• Maintain accurate denial, review, and appeal records in databases.

Kenntnisse

RN license

Case management

Utilization review

Medical records review

Clinical judgment

Jobbeschreibung

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote United States position. You will use your nursing expertise to evaluate medical records, assess medical necessity, and manage appeals to support patient care and financial performance.

Collaborate with physicians, medical directors, and payer representatives to resolve complex cases, improve review processes, and ensure compliance with payer policies and clinical criteria.