Remote Utilization Review Case Manager

Quorum Health Corporation; Brentwood (TN); Remote; USD 70,000 - 100,000; Full time

Job summary

Quorum Health Corporation is seeking an Utilization Review Specialist licensed as an RN to oversee admission reviews and appeals. The role focuses on preventing denials across payers and coordinating with the UR committee for appropriate actions.

Responsibilities include analyzing records, applying InterQual/Milliman criteria, and ensuring timely documentation and reporting. This remote-friendly role emphasizes collaboration and accuracy in appeal processing.

Qualifications

• Current state-issued RN license.
• Knowledge of InterQual Level of Care Criteria and Milliman & Robertson Criteria.
• Experience with third party payer regulations related to utilization and quality review.

Responsibilities

• Analyzes patient records to determine admission, treatment, and length of stay per policies.
• Approves admissions or refers case to UR committee for action when standards are not met.
• Compares inpatient records to criteria and consults with medical staff to determine legitimacy.
• Abstracts data from records and maintains statistics.
• Coordinate first, second and third level appeals.
• Monitor appeal timelines and collaborate with departments to resolve issues.
• Ensure proper documentation of denials in billing systems.
• Prepare and present information on appeals to committees.

Skills

Case management

HIPAA compliance

Clinical documentation

Communication skills

Education

RN license

Nursing degree

Tools

InterQual Criteria

Milliman & Robertson Criteria

Job description

Quorum Health Corporation is seeking an Utilization Review Specialist licensed as an RN to oversee admission reviews and appeals. The role focuses on preventing denials across payers and coordinating with the UR committee for appropriate actions.

Responsibilities include analyzing records, applying InterQual/Milliman criteria, and ensuring timely documentation and reporting. This remote-friendly role emphasizes collaboration and accuracy in appeal processing.