Case Manager - Utilization Review Specialist
New
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JobgetherHealthcare utilization management
Applicants must live in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Tennessee, Texas, Utah, or Wyoming to be eligible for this remote position.Full-TimeManager
Salary not disclosed
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Job Details
- Experience
- 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.
- Required Skills
- HIPAA
Requirements
- Hold a current, active registered nurse (RN) license issued by a U.S. state.
- Have at least five years of clinical nursing experience in an acute care setting.
- Bring five to seven years of case management, discharge planning, utilization review, or related healthcare experience; preferred.
- Know healthcare utilization management practices, payer requirements, reimbursement policies, and regulatory standards.
- Be familiar with clinical decision-support criteria such as InterQual and Milliman & Robertson/MCG care guidelines; preferred.
- Review complex clinical records, assess medical necessity and treatment plans, and make sound patient care and discharge-planning decisions.
- Have experience preparing and coordinating clinical or administrative appeals; highly desirable.
- Analyze denial trends, investigate root causes, and recommend corrective actions.
- Write professional appeal letters, technical reports, and supporting documentation.
- Interpret and extract relevant information from complex medical records, including handwritten documentation.
- Use data-entry, recordkeeping, and database-management practices to maintain accurate review and appeal records.
- Manage multiple cases, deadlines, and priorities while working independently and exercising sound clinical judgment.
- Maintain patient confidentiality and comply with HIPAA and other applicable healthcare requirements.
Responsibilities
- Conduct admission and concurrent utilization reviews for medical necessity, treatment appropriateness, and length of stay.
- Analyze medical records, insurance requirements, reimbursement policies, and accreditation standards against established criteria.
- Identify potential reimbursement denials, investigate root causes, and recommend workflow improvements.
- Review clinical documentation and claim histories to determine appropriate next steps, including appeals.
- Coordinate first-, second-, and third-level appeals and ensure complete supporting documentation is submitted by deadlines.
- Draft appeal letters supported by clinical evidence, medical records, payer policies, regulations, and relevant statutes.
- Assign reviews to physician advisors and medical directors when additional clinical expertise is needed.
- Monitor appeal timelines, decisions, and outcomes and collaborate with internal departments to resolve outstanding issues.
- Maintain accurate records of denials, reviews, appeals, and outcomes in databases and billing systems.
- Prepare and present appeal findings, utilization review data, and performance reports; support audits and quality improvement activities.
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