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United States
Remote only
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Case Manager – Utilization Review Specialist based in the United States.
Join a healthcare team dedicated to improving utilization management, strengthening reimbursement outcomes, and ensuring compliance with clinical and payer requirements. In this remote role, you will oversee admission and concurrent utilization reviews, identify potential reimbursement denials, and coordinate appeals to support appropriate patient care and financial performance. You will apply your clinical nursing expertise to evaluate medical records, assess medical necessity, and develop evidence-based appeals. Working closely with case managers, physicians, medical directors, and payer representatives, you will help resolve complex cases and improve review processes. Your work will contribute to quality improvement initiatives, timely appeal resolutions, and more effective healthcare administration. This opportunity is ideal for an experienced nursing professional who combines clinical judgment, analytical thinking, and strong communication skills in a fast-paced, independent working environment.
Conduct admission and concurrent utilization reviews to assess medical necessity, appropriateness of treatment, and length of stay in accordance with established clinical criteria, payer policies, and applicable regulations.
Analyze patient medical records, insurance requirements, government reimbursement policies, and accreditation standards to determine whether admissions and ongoing treatment meet established criteria.
Identify potential reimbursement denials, investigate their underlying causes, and develop strategies to prevent recurring issues through workflow improvements and stronger utilization review practices.
Review clinical documentation and claim histories to determine appropriate next steps, including identifying cases requiring administrative or clinical appeals.
Coordinate first-, second-, and third-level appeals, ensuring supporting documentation is complete and submissions meet required deadlines.
Draft clear, professional appeal letters supported by clinical evidence, medical records, payer policies, applicable regulations, and relevant statutes.
Assign medical necessity reviews to physician advisors and medical directors when additional clinical expertise is required.
Monitor appeal timelines, decisions, and outcomes while collaborating with internal departments to resolve outstanding issues efficiently.
Maintain accurate documentation of denials, utilization reviews, appeal activities, and outcomes in the appropriate databases and billing systems.
Establish and maintain professional relationships with payer utilization management and appeals departments to facilitate communication and timely case resolution.
Collaborate with case managers, clinical supervisors, account managers, and other healthcare professionals to resolve complex utilization review and reimbursement challenges.
Track appeal volumes, identify resource needs, and coordinate additional support when necessary to maintain operational efficiency.
Prepare and present appeal findings, utilization review data, and performance reports to relevant committees and stakeholders.
Conduct and support appeals audits, monitor quality improvement activities, and recommend process enhancements based on performance trends and identified gaps.
Maintain accurate statistics and determine review schedules according to established clinical criteria and operational requirements.
Support utilization review committees and quality assurance activities as needed, including reviews required by applicable federal regulations.
Protect the confidentiality of patient information and medical records in accordance with HIPAA and other applicable privacy requirements.
Perform additional duties as assigned to support the effectiveness of utilization management and appeals operations.
Current, active registered nurse (RN) license issued by a U.S. state is required.
At least 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.
Familiarity with established clinical decision-support criteria, such as InterQual and Milliman & Robertson (now commonly associated with MCG care guidelines), is preferred.
Demonstrated ability to review complex clinical records, assess medical necessity, evaluate treatment plans, and make sound decisions regarding patient care and discharge planning.
Experience preparing and coordinating clinical or administrative appeals, including the ability to support arguments with clinical evidence, regulatory guidance, payer policies, and relevant documentation, is highly desirable.
Strong analytical and critical-thinking skills, with the ability to identify denial trends, investigate root causes, and recommend effective corrective actions.
Excellent written communication skills, including the ability to prepare professional appeal letters, technical reports, and supporting documentation.
Strong verbal communication and interpersonal skills, with the ability to collaborate effectively with physicians, nurses, case managers, medical directors, payer representatives, and other stakeholders.
Ability to interpret and extract relevant information from complex medical records, including handwritten documentation.
Proficiency in data entry, recordkeeping, database management, and maintaining accurate documentation of reviews, appeals, and outcomes.
Strong organizational and time-management skills, with the ability to manage multiple cases, monitor deadlines, and prioritize competing responsibilities.
Ability to work independently, exercise sound clinical judgment, and adapt quickly to changing regulations, workflows, and operational priorities.
A commitment to confidentiality, professional ethics, accuracy, and compliance with HIPAA and other applicable healthcare requirements.
Flexibility, attention to detail, accountability, and a willingness to continuously learn and improve processes.
Residency requirement: Applicants must live in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Tennessee, Texas, Utah, or Wyoming to be eligible for this remote position.
Remote work: Full-time remote work arrangement, subject to the position's eligible-state residency requirements.
Clinical impact: The opportunity to apply nursing expertise to utilization management, medical necessity reviews, denial prevention, and patient care coordination.
Professional collaboration: Work closely with clinical teams, physicians, medical directors, case managers, and payer representatives.
Process improvement: Contribute to quality improvement initiatives, appeals performance, and the development of more effective utilization review workflows.
Compensation: Salary range and additional compensation details were not specified in the source job description and should be confirmed during the recruitment process.
Healthcare coverage: Medical, dental, vision, and other insurance benefits were not detailed in the source posting; availability and eligibility should be confirmed with the hiring team.
Additional benefits: Paid time off, retirement plans, paid leave, professional development support, and other employee perks were not specified in the source description and should be verified during recruitment.
