Remote Utilization Review Case Manager

Jobgether; Crystal Bay (NV); Remote; USD 90,000 - 120,000; Full time

Job summary

Jobgether is partnering with a healthcare team to fill a Case Manager – Utilization Review Specialist role. This remote position oversees admission and concurrent reviews, supports appeals, and coordinates with physicians, nurses, and payers to ensure compliant, efficient patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, determine medical necessity, draft appeals, and manage documentation while upholding HIPAA and regulatory standards.

Qualifications

• Five+ years of clinical nursing experience in acute care is required.
• Experience in case management, discharge planning, or utilization review is preferred.

Responsibilities

• Analyze patient medical records to determine if admissions and ongoing treatment meet criteria.
• Identify potential reimbursement denials and develop prevention strategies.
• Review clinical documentation and claim histories to determine next steps for appeals.
• Coordinate first- to third-level appeals with complete documentation.
• Draft professional appeal letters with supporting clinical evidence.

Skills

Clinical nursing

Utilization review

Discharge planning

Appeals coordination

Regulatory knowledge

HIPAA

Communication

Documentation

Education

Registered Nurse license (RN)

Tools

InterQual

MCG care guidelines

Job description

Jobgether is partnering with a healthcare team to fill a Case Manager – Utilization Review Specialist role. This remote position oversees admission and concurrent reviews, supports appeals, and coordinates with physicians, nurses, and payers to ensure compliant, efficient patient care and financial performance.

You will apply clinical nursing expertise to evaluate records, determine medical necessity, draft appeals, and manage documentation while upholding HIPAA and regulatory standards.