Case Manager – Utilization Review Specialist

This is a fully remote position, open to applicants in California, +9 more states.

📋 Description

• Take charge of admission and concurrent reviews to avoid payer denials.

• Appeal accounts that have been assessed and deemed suitable for appeal.

• Identify trends in denials and develop strategies to address root causes through workflow enhancements.

• Examine patient records to ascertain the validity of admissions, treatments, and lengths of stay.

• Evaluate standards set by insurance, governmental bodies, and accrediting agencies.

• Review patient admission applications to approve admissions or refer cases to utilization review committees.

• Compare inpatient medical records against established criteria and consult with medical, nursing, and professional personnel.

• Extract data from records and maintain statistical information.

• Determine review dates for patients based on diagnostic criteria.

• Assist with federally mandated quality assurance evaluations.

• Investigate clinical records, insurance regulations, and claims history to decide on subsequent actions.

• Oversee compliance with appeal decision timelines and work with departments to resolve any issues.

• Review records for completeness and identify whether an appeal is administrative or clinical.

• Assign cases requiring medical necessity reviews to physician advisors and medical directors.

• Coordinate first, second, and third-level appeals.

• Consult with managers and collaborate with case managers, clinical supervisors, account managers, and other staff.

• Document denials in billing systems and track results for reporting purposes.

• Manage appeals and monitor appeal volumes to mobilize additional resources.

• Foster professional relationships with payer appeals and utilization departments.

• Input appeal and case review data into a database.

• Prepare and present appeal information to committees and staff members.

• Prepare for and conduct appeals audits.

• Monitor and report on Quality Improvement activities.

• Draft professional appeal letters using supporting documents, policies, and statutes.

• Perform additional duties as required.

⛳️ Requirements

• Valid state-issued RN license.

• Extensive experience in the healthcare industry.

• At least five years of experience as a clinical nurse in an acute care environment.

• Preferred experience of five to seven years in case management, discharge planning, and/or utilization review.

• Familiarity with InterQual Level of Care Criteria and Milliman & Robertson Criteria is preferred.

• Understanding of third-party payer regulations pertaining to utilization and quality review is preferred.

• Knowledge of regulatory and payer requirements for Case Management Activities.

• Ability to critically assess and make decisions regarding discharge planning for complex cases.

• Capability to utilize existing criteria sets and/or clinical evidence from established libraries of clinical references and regulatory arguments to support clinical appeal arguments.

• Maintain confidentiality of patient data and medical records in accordance with HIPAA regulations.

• Proficient in reading, evaluating, and abstracting critical information from handwritten patient medical records.

• Excellent oral communication, technical writing, and typing abilities.

• Flexibility and eagerness to learn and adapt to changes in regulations and task priorities.

• Ability to work independently and swiftly adapt to changing priorities and regulations.

• Must reside in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Utah, Tennessee, Texas, or Wyoming.

🏝️ Benefits

• Competitive salary package.

• Comprehensive health, dental, and vision insurance.

• Opportunities for professional development and continuing education.

• Flexible work hours and supportive work environment.