Case Manager - Utilization Review Specialist - Remote

Quorum Health•Brentwood, TN

18h•Remote

About The Position

The Utilization Review Specialist is accountable for admission and concurrent reviews to help prevent payer denials, and for appealing accounts determined to be appropriate for appeal. The role identifies denial trends and opportunities to improve workflows and develop processes to address root causes. The position is remote and is available only to candidates residing in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Utah, Tennessee, Texas, or Wyoming. The Specialist reviews clinical and administrative records, payer and regulatory requirements, and established criteria to assess admissions, treatment, length of stay, and appeals. The role coordinates appeals at multiple levels, tracks decisions and deadlines, supports audits and quality improvement activities, and works with clinical, operational, payer, and physician stakeholders to resolve denial and appeal issues.

Requirements

Current state-issued RN license.
Significant healthcare experience, including at least five years as a clinical nurse in an acute care setting.
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 existing criteria sets, clinical evidence, clinical references, and regulatory arguments to support clinical appeals.
Maintain 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 communication, technical writing, and typing skills.
Flexibility and willingness to learn and adapt to regulatory changes and task priorities.
Ability to work independently and adapt quickly to changing priorities and regulations.

Nice To Haves

Knowledge of InterQual Level of Care Criteria.
Knowledge of Milliman & Robertson Criteria.
Knowledge of third-party payer regulations related to utilization and quality review.
Five to seven years of experience in case management, discharge planning, and/or utilization review.

Responsibilities

Analyze patient records and applicable insurance, governmental, and accrediting standards to determine the legitimacy of admission, treatment, and length of stay.
Review admission applications and approve admissions or refer cases that do not meet standards to the facility utilization review committee.
Compare inpatient medical records with established criteria and confer with medical, nursing, and other professional staff about treatment and length of stay.
Abstract data from records and maintain statistics; determine patient review dates using established diagnostic criteria.
Assist the review committee with planning and conducting federally mandated quality assurance reviews, as needed.
Supervise and coordinate utilization review staff activities, as needed.
Research clinical records, insurance regulations, and claim history to determine next steps.
Monitor appeal decision time frames and collaborate with other departments to resolve issues and appeals on time.
Review clinical and medical records for completeness, determine whether appeals are administrative or clinical, and assign medical-necessity reviews to physician advisors and medical directors.
Coordinate first-, second-, and third-level appeals and manage them to ensure timely submission.
Consult with managers and work with case managers, clinical supervisors, account managers, and other personnel to resolve denial and appeal questions.
Document denials in billing systems and track outcomes for reporting.
Monitor appeal volume and engage additional resources when needed.
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 as requested.
Prepare for and complete appeals audits.
Monitor and report appeals department Quality Improvement activities.
Draft professional appeal letters using supporting documents, policies, and statutes.
Perform other duties as assigned.