Remote Utilization Review Case Manager & Appeals (RN)

Jobgether; California; Remote; USD 110,000 - 150,000; Full time

Job summary

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

You will apply clinical nursing expertise to evaluate records, identify denials, and work with physicians, directors, and payer representatives to resolve complex cases and improve review processes.

Qualifications

• Minimum 5 years of clinical nursing experience in an acute care setting.
• 5–7 years of experience in case management, discharge planning, utilization review, or related healthcare discipline preferred.
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards.
• Familiarity with clinical decision-support criteria such as InterQual and MCG guidelines.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Identify potential reimbursement denials and develop prevention strategies through workflow improvements.
• Review clinical documentation and claim histories to determine next steps, including appeals.
• Coordinate first-, second-, and third-level appeals with deadlines and appropriate documentation.
• Draft professional appeal letters supported by clinical evidence and payer policies.
• Assign reviews to physician advisors when additional expertise is required.
• Maintain accurate documentation of denials, reviews, and outcomes in systems.
• Collaborate with medical staff and payer representatives to resolve UM and reimbursement challenges.
• Prepare and present appeal findings and performance reports to committees.
• Support audits, quality improvement initiatives, and required regulatory reviews.
• Protect patient confidentiality per HIPAA and privacy requirements.

Skills

Clinical nursing

Utilization review

Discharge planning

Payer policies

Regulatory standards

Written communication

Interpersonal skills

Data entry

Education

RN license

Tools

InterQual

MCG care guidelines

Job description

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

You will apply clinical nursing expertise to evaluate records, identify denials, and work with physicians, directors, and payer representatives to resolve complex cases and improve review processes.