Case Manager - Utilization Review Specialist

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…