Remote Utilization Review Case Manager | Nursing Expert

Jobgether; Austin (TX); À distance; USD 90 000 - 120 000; Plein temps

Avantages offerts par ce poste

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Résumé du poste

Jobgether is seeking a Case Manager – Utilization Review Specialist to oversee admissions and concurrent reviews, evaluate medical necessity, and coordinate clinical and administrative appeals. You will work remotely from the United States alongside physicians, case managers, and payer representatives to improve review processes and reimbursement outcomes.

Ideal candidates will have five or more years of acute care nursing and five to seven years in case management or utilization review, with

Qualifications

• Five years of clinical nursing in acute care.
• Five to seven years in case management, discharge planning, utilization review, or related healthcare discipline.
• Strong knowledge of utilization management practices, payer requirements, and regulatory standards.

Responsabilités

• Conduct admission and concurrent utilization reviews to assess medical necessity and appropriateness of care.
• Identify potential reimbursement denials and develop strategies to prevent recurring issues.
• Coordinate first-, second-, and third-level appeals with physician advisors and medical directors.
• Draft professional appeal letters supported by clinical evidence and payer policies.
• Maintain documentation of denials, reviews, and outcomes in billing systems.

Description du poste

Jobgether is seeking a Case Manager – Utilization Review Specialist to oversee admissions and concurrent reviews, evaluate medical necessity, and coordinate clinical and administrative appeals. You will work remotely from the United States alongside physicians, case managers, and payer representatives to improve review processes and reimbursement outcomes.

Ideal candidates will have five or more years of acute care nursing and five to seven years in case management or utilization review, with