Case Manager - Utilization Review Specialist

Quorum Health Corporate•Brentwood, TN

1d•Remote

About The Position

The Utilization Review Specialist is accountable for admission and concurrent reviews, preventing payer denials, and appealing accounts when appropriate. The role identifies denial trends and opportunities to improve workflows. It reviews patient records and payer, governmental, and accrediting standards to assess admissions, treatment, and length of stay, and supports timely, well-documented appeals and quality improvement activities. This is a remote, full-time position limited to candidates residing in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Utah, Tennessee, Texas, or Wyoming.

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 references, and regulatory arguments to support clinical appeals.
Ability to maintain patient-data and medical-record confidentiality in compliance with HIPAA.
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 changing regulations and 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 assess admission legitimacy, treatment, and length of stay.
Review admission applications and approve admissions or refer cases that do not meet admission standards to the facility utilization review committee.
Compare inpatient medical records with established criteria and consult medical, nursing, and other professional staff about treatment and length-of-stay determinations.
Abstract information from records, maintain statistics, and determine patient review dates according to diagnostic criteria.
Research clinical records, insurance regulations, and claim histories to determine appropriate next steps.
Monitor appeal decision time frames and collaborate with other departments to resolve issues or appeals promptly.
Review clinical and medical records for completeness and determine whether an appeal is administrative or clinical.
Assign medical-necessity reviews to physician advisors and medical directors.
Coordinate first-, second-, and third-level appeals and manage appeals to ensure timely submission.
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 supported by relevant documents, policies, and statutes.
Consult managers on problem cases and work with case managers, clinical supervisors, account managers, and others to resolve denial and appeal questions.
May assist utilization review committees with federally mandated quality assurance reviews.
May supervise and coordinate utilization review staff.
Perform other duties as assigned.