Remote Utilization Review Case Manager & Appeals Lead

Jobgether; Massachusetts; Remote; USD 90,000 - 130,000; Full time

Job summary

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote position based in the United States. You will oversee admission and concurrent utilization reviews, assess medical necessity, and coordinate administrative and clinical appeals to support appropriate patient care and financial performance.

You will apply your clinical nursing expertise to evaluate records, collaborate with clinicians, and ensure compliance with payer requirements and regulations.

Qualifications

• Five years of clinical nursing experience in an acute care setting is required.
• Five to seven years of experience in case management, discharge planning, utilization review, or a closely related healthcare discipline is preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards governing case management activities.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Identify potential reimbursement denials and develop strategies to prevent recurring issues through workflow improvements.
• Coordinate first-, second-, and third-level appeals with supporting documentation and deadlines.
• Draft professional appeal letters with clinical evidence, payer policies, and relevant regulations.
• Maintain documentation of denials, utilization reviews, and appeal outcomes in databases and billing systems.
• Collaborate with physicians, nurses, case managers, medical directors, and payer representatives to resolve complex utilization review challenges.
• Prepare and present appeal findings and utilization review data to committees and stakeholders.
• Support utilization review committees and quality assurance activities as needed, including HIPAA privacy compliance.

Job description

Jobgether is seeking a Case Manager – Utilization Review Specialist for a remote position based in the United States. You will oversee admission and concurrent utilization reviews, assess medical necessity, and coordinate administrative and clinical appeals to support appropriate patient care and financial performance.

You will apply your clinical nursing expertise to evaluate records, collaborate with clinicians, and ensure compliance with payer requirements and regulations.