Case Manager - Utilization Review Specialist

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.

• 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.