Case Review Manager – Independent Reviews, IRO/UR

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $85k - $95k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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RediMinds, Inc

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11 - 50 employees

Founded 2016

🏥 Healthcare

🤖 Artificial Intelligence

☁️ SaaS

💰 $225k Grant on 2020-05

Healthcare • Artificial Intelligence • SaaS

RediMinds is a healthcare technology company that builds and operates AI-powered platforms to support regulated medical review, arbitration, and other high‑stakes healthcare decisions. Their products automate intake, document indexing, evidence extraction, timeline and clinical summary generation, reviewer matching and credentialing, and produce audit-ready, human‑supervised determinations for workflows such as prior authorization/ePA, federal and state independent dispute resolution (IDR), state external review, Social Security disability, workers’ compensation, fraud/waste/abuse detection, and DRG review. The company emphasizes human-in-the-loop decisioning (AI prepares the work; qualified clinicians sign determinations), regulatory defensibility, and compliance with healthcare security standards (URAC, HITRUST, SOC 2, HIPAA), and publishes peer‑reviewed research.

📋 Description

• Review incoming case files for completeness and accuracy, including case summaries, member and service details, clinical records, supporting documents, and key dates • Identify missing or inconsistent information • Validate system-generated summaries and case information against underlying records • Escalate discrepancies and ensure a reliable foundation for clinician review • Quality-check clinicians’ written reviews for completeness, internal consistency, clear rationale, accurate evidence references, and responsiveness to the question under review • Work directly with clinicians to clarify or correct documentation gaps while preserving independent clinical judgment and decision-making authority • Perform final quality assurance on determination letters before issuance • Coordinate with clinical and operations teams to resolve issues, maintain accurate case records, and meet standard and expedited review deadlines • Protect confidential health information and follow independence and conflict-of-interest safeguards • Identify opportunities to strengthen quality and improve workflows

🎯 Requirements

• Hands-on experience in utilization review (UR), healthcare appeals, independent review, clinical review operations, or closely related medical-record and decision-document quality assurance • Ability to read and critically assess clinical documentation, identify omissions or inconsistencies, and raise well-founded questions for the appropriate clinical reviewer • Excellent written communication and editing skills • Exceptional attention to detail, sound judgment, and ability to manage multiple cases against firm deadlines • Comfort working in technology-enabled systems and independently verifying summaries, documents, and other system outputs against source records • Understanding 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 • Evening or weekend work may be required when needed to meet regulatory deadlines • Direct experience with an Independent Review Organization (IRO), external grievance reviews, or external healthcare appeals is especially valuable but not required • Experience with Pennsylvania Personal Assistance Services (PAS) cases, Community HealthChoices, Medicaid managed care, or long-term services and supports (LTSS) is welcome but not required • Experience auditing clinical review rationales and final determination or appeal letters is especially valuable but not required • Clinical credential such as RN or LPN/LVN or relevant clinical training is especially 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

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