Case Manager - Utilization Review Specialist.

Accountabilities

• 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.

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 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.

Benefits:

• 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.