Remote Utilization Management Leader

Jobgether SRL; United States; Remote; USD 92,000 - 139,000; Full time

Benefits offered by this job

Healthcare benefits

Paid time off and retirement benefits

Tuition reimbursement

Career advancement opportunities

Job summary

Jobgether SRL is representing a partner company based in the United States, seeking an experienced Utilization Review Manager to lead a centralized Virtual Utilization Management program. This remote leadership role oversees utilization review, authorizations, denials, and appeals for inpatient, observation, and outpatient services.

The candidate will drive compliance with Medicare/Medicaid regulations, apply MCG criteria, manage budgets, and leverage AI to enhance efficiency and outcomes.

Qualifications

• Associate degree in Nursing is required; a Bachelor’s degree in Nursing is preferred.
• MCG or equivalent medical-necessity criteria proficiency is required.
• Experience in utilization management, clinical review, denials and appeals, or related healthcare operations.
• Strong knowledge of insurance, Medicare/Medicaid regulations, and regulatory guidelines.
• Experience managing teams and monitoring productivity and quality.

Responsibilities

• Lead centralized Virtual Utilization Management program across utilization review activities.
• Oversee authorizations, denials, and appeals for inpatient, observation, and outpatient services.
• Develop annual utilization management work plans and report progress to senior leadership.
• Provide resources to virtual teams and collaborate with Care Coordination and Clinical Documentation functions.
• Identify opportunities to reduce denials, improve appeal outcomes, and optimize reimbursement.

Skills

Utilization management

Clinical review

Team leadership

Regulatory compliance

AI in healthcare

Budget management

Stakeholder management

Education

Associate degree in Nursing

Bachelor’s degree in Nursing preferred

Tools

MCG criteria

Data analytics tools

Job description

Jobgether SRL is representing a partner company based in the United States, seeking an experienced Utilization Review Manager to lead a centralized Virtual Utilization Management program. This remote leadership role oversees utilization review, authorizations, denials, and appeals for inpatient, observation, and outpatient services.

The candidate will drive compliance with Medicare/Medicaid regulations, apply MCG criteria, manage budgets, and leverage AI to enhance efficiency and outcomes.