Case Manager – Utilization Review Specialist

Job not on LinkedIn

🔥 0 minutes ago

🏄 California, Kentucky, +8 more states – Remote

🏄 California – Remote 🐎 Kentucky – Remote 🎰 Nevada – Remote 🌶️ New Mexico – Remote 🌲 Oregon – Remote 🍂 Massachusetts – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🦬 Wyoming – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Quorum Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2016

🏥 Healthcare

👥 B2C

Healthcare • B2C

Quorum Health is an operator of general acute care hospitals that owns or operates 12 hospitals across nine U. S. states. The company partners with local providers and subsidiaries to deliver inpatient and community-based healthcare services, focusing on quality, safety, and supporting local economies and workforce development. Quorum Health emphasizes community investment, hospital administration, and empowering local teams to provide patient-centered care.

📋 Description

• Assume responsibility and accountability for admission and concurrent reviews to prevent payer denials • Appeal accounts reviewed and deemed appropriate for appeal • Identify denial trends and create structures to resolve root causes through workflow improvements • Analyze patient records to determine legitimacy of admission, treatment, and length of stay • Analyze insurance, governmental, and accrediting agency standards • Review patient admission applications and approve admissions or refer cases to utilization review committees • Compare inpatient medical records with established criteria and consult medical, nursing, and professional staff • Abstract data from records and maintain statistics • Determine patient review dates according to diagnostic criteria • Assist with federally mandated quality assurance reviews • Research clinical records, insurance regulations, and claim history to determine next steps • Monitor compliance with appeal decision time frames and collaborate with departments to resolve issues • Review records for completeness and determine administrative or clinical appeal • Assign reviews requiring medical necessity review to physician advisors and medical directors • Coordinate first-, second-, and third-level appeals • Consult with managers and interface with case managers, clinical supervisors, account managers, and other personnel • Document denials in billing systems and track outcomes for reporting • Manage appeals and monitor appeal volume to engage additional resources • Build professional relationships with payer appeals and utilization departments • Enter appeal and case review data into a database • Prepare and present appeal information to committees and personnel • Prepare for and complete appeals audits • Monitor and report Quality Improvement activities • Draft professional appeal letters using supporting documents, policies, and statutes • Perform other duties as assigned

🎯 Requirements

• Current state-issued RN license • Significant experience in the healthcare field • Minimum of five years as a clinical nurse in an acute care setting • At least five to seven years of experience in case management, discharge planning, and/or utilization review preferred • Knowledge of InterQual Level of Care Criteria and Milliman & Robertson Criteria preferred • Knowledge of third party payer regulations related to utilization and quality review preferred • Knowledge of regulatory and payer requirements for Case Management Activities • Ability to critically evaluate and make decisions about discharge planning for highly difficult cases • Ability to use pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support clinical appeals arguments • Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations • Ability to read, evaluate, and abstract important information from handwritten patient medical records • Excellent oral and technical writing and typing skills • Flexibility and willingness to learn and adapt to changes in regulations and task-related priorities • Ability to work independently and adapt quickly to changing priorities and regulations • Must reside in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Utah, Tennessee, Texas, or Wyoming