Case Manager - Utilization Review Specialist

📋 Description

• Conduct admission and concurrent utilization reviews to assess medical necessity, appropriateness
• Analyze patient medical records, insurance requirements, government reimbursement policies, and
• Identify potential reimbursement denials, investigate their underlying causes, and develop
• Review clinical documentation and claim histories to determine appropriate next steps, including
• Coordinate first-, second-, and third-level appeals, ensuring supporting documentation is complete
• Draft clear, professional appeal letters supported by clinical evidence, medical records, payer

🎯 Requirements

• 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
• Strong knowledge of healthcare utilization management practices, payer requirements, reimbursement
• Familiarity with established clinical decision-support criteria, such as InterQual and Milliman
• Demonstrated ability to review complex clinical records, assess medical necessity, evaluate

🎁 Benefits

• Remote work: Full-time remote work arrangement, subject to the position's eligible-state residency
• Clinical impact: The opportunity to apply nursing expertise to utilization management, medical
• Professional collaboration: Work closely with clinical teams, physicians, medical directors, case
• Process improvement: Contribute to quality improvement initiatives, appeals performance, and the
• Compensation: Salary range and additional compensation details were not specified in the source job
• Healthcare coverage: Medical, dental, vision, and other insurance benefits were not detailed in the