Remote Utilization Review Case Manager & Appeals Specialist

Jobgether; Boston (MA); Remote; USD 85,000 - 120,000; Full time

Job summary

Jobgether, listing on behalf of a partner company, seeks a Case Manager – Utilization Review Specialist in the United States. The remote role focuses on admission and concurrent reviews, appeals coordination, and ensuring compliance with clinical and payer requirements.

A clinical nursing background with extensive utilization management experience is required. You will analyze medical records, assess medical necessity, and collaborate with physicians, medical directors, and payer representatives

Qualifications

• At least five years of clinical nursing experience in an acute care setting is required.

Responsibilities

• Conduct admission and concurrent utilization reviews to assess medical necessity and length of stay.
• Identify potential reimbursement denials and coordinate administrative or clinical appeals.
• Draft clear appeal letters with clinical evidence and payer policies.
• Coordinate first-, second-, and third-level appeals and ensure timely submissions.
• Maintain documentation of denials, reviews, and outcomes in appropriate systems.
• Prepare and present appeal findings and utilization data to committees.

Skills

Nursing experience

Case management

Discharge planning

Clinical documentation

Written communication

Verbal communication

InterQual/MG C guidelines familiarity

Tools

InterQual

Milliman & Robertson

Job description

Jobgether, listing on behalf of a partner company, seeks a Case Manager – Utilization Review Specialist in the United States. The remote role focuses on admission and concurrent reviews, appeals coordination, and ensuring compliance with clinical and payer requirements.

A clinical nursing background with extensive utilization management experience is required. You will analyze medical records, assess medical necessity, and collaborate with physicians, medical directors, and payer representatives