Case Review Manager – Independent Reviews, IRO/UR

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess incoming case files for completeness and accuracy, including case summaries, member and service details, clinical records, supporting documents, and key dates.

• Detect missing or inconsistent information.

• Verify system-generated summaries and case details against underlying records.

• Report discrepancies and ensure a dependable foundation for clinician review.

• Conduct quality checks on clinicians’ written reviews for thoroughness, internal consistency, clear rationale, accurate evidence references, and responsiveness to the inquiry under review.

• Collaborate directly with clinicians to clarify or rectify documentation gaps while maintaining independent clinical judgment and decision-making authority.

• Execute final quality assurance on determination letters prior to issuance.

• Work with clinical and operations teams to address issues, uphold accurate case records, and meet both standard and expedited review deadlines.

• Safeguard confidential health information and adhere to independence and conflict-of-interest protocols.

• Recognize opportunities to enhance quality and optimize workflows.

⛳️ Requirements

• Practical experience in utilization review (UR), healthcare appeals, independent review, clinical review operations, or closely related medical record and decision-document quality assurance.

• Capability to read and critically evaluate clinical documentation, identify omissions or inconsistencies, and pose well-founded questions for the appropriate clinical reviewer.

• Outstanding written communication and editing skills.

• Remarkable attention to detail, sound judgment, and the ability to manage multiple cases under strict deadlines.

• Comfort in working with technology-enabled systems and independently verifying summaries, documents, and other system outputs against source records.

• Knowledge of patient confidentiality and impartial, well-documented healthcare review processes.

• Bachelor’s degree in a healthcare-related field or an equivalent combination of education and relevant experience.

• Availability for evening or weekend work may be necessary to meet regulatory deadlines.

• Direct experience with an Independent Review Organization (IRO), external grievance reviews, or external healthcare appeals is particularly valuable but not mandatory.

• Experience with Pennsylvania Personal Assistance Services (PAS) cases, Community HealthChoices, Medicaid managed care, or long-term services and supports (LTSS) is appreciated but not required.

• Experience auditing clinical review rationales and final determination or appeal letters is especially valuable but not required.

• Clinical credentials such as RN or LPN/LVN or relevant clinical training is particularly valuable but not required.

🏝️ Benefits

• Fully remote work arrangement.

• Self-directed role with close collaboration across clinical and operations teams.

• Equal opportunity and inclusive work environment.