Remote Utilization Review Case Manager & Appeals Expert

Jobgether; California City (CA); Remote; USD 80,000 - 140,000; Full time

Job summary

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote role in the United States. You will conduct admission and concurrent reviews, assess medical necessity, and coordinate complex appeals to support patient care and financial performance.

You will work with case managers, physicians, medical directors, and payer representatives to improve review processes, ensure compliance with regulations, and maintain documentation across databases and billing systems.

Qualifications

• RN license and clinical nursing experience required.
• 5+ years in case management or utilization review preferred.
• Experience with appeals and denials processes is highly desirable.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and LOS.
• Identify potential reimbursement denials and develop prevention strategies.
• Coordinate first-, second-, and third-level appeals with complete documentation.
• Draft professional appeal letters supported by clinical evidence and payer policies.
• Assign reviews to physician advisors when needed.
• Maintain accurate documentation of reviews, denials, and outcomes.
• Collaborate with physicians, case managers, medical directors, and payer representatives.
• Support quality improvement initiatives and appeal performance tracking.

Skills

Clinical nursing

Utilization review

Appeals coordination

Documentation

HIPAA compliance

Communication skills

Education

RN license

Tools

EMR systems

Payer portals

Job description

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote role in the United States. You will conduct admission and concurrent reviews, assess medical necessity, and coordinate complex appeals to support patient care and financial performance.

You will work with case managers, physicians, medical directors, and payer representatives to improve review processes, ensure compliance with regulations, and maintain documentation across databases and billing systems.