Case Review Manager – Independent Reviews (IRO/UR)

RediMinds, Inc

11h • $85,000 - $95,000 • Remote

About The Position

RediMinds is hiring Case Review Managers for Independent Reviews (IRO/UR) to safeguard quality when cases enter the system and before final determinations are issued. The role combines review of case documentation, verification of system-generated information, quality checks of clinicians’ written reviews, and final quality assurance of determination letters. Much of the administrative workflow is automated, while the Case Review Manager provides judgment, attention to detail, and clear writing to ensure accurate, complete, and timely cases.

This is a fully remote, self-directed role involving close collaboration with clinical and operations teams. The Case Review Manager is accountable for documentation and process quality, while independent clinicians retain responsibility for clinical determinations. Evening or weekend work may be required to meet regulatory deadlines.

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, including the ability to make complex, sensitive determinations clear, accurate, and consistent.
• 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.

Nice To Haves

• Direct experience with an Independent Review Organization (IRO), external grievance reviews, or external healthcare appeals.
• Experience with Pennsylvania Personal Assistance Services (PAS) cases; related experience in Community HealthChoices, Medicaid managed care, or long-term services and supports (LTSS) is also welcome.
• Experience auditing clinical review rationales and final determination or appeal letters for quality and regulatory completeness.
• A clinical credential, such as RN or LPN/LVN, or relevant clinical training.

Responsibilities

• Review incoming case files for completeness and accuracy, including 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 source records, escalating discrepancies and ensuring 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 with clinicians to clarify or correct documentation gaps while preserving their independent clinical judgment and decision-making authority.
• Perform final quality assurance on determination letters before issuance, ensuring they reflect clinician findings, are clear and professional, and meet case-specific requirements.
• Coordinate with clinical and operations teams to resolve issues, maintain accurate case records, and meet standard and expedited review deadlines.
• Protect confidential health information, follow independence and conflict-of-interest safeguards, and identify opportunities to strengthen quality and improve workflows.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level