Case Manager - Utilization Review Specialist

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Case Manager – Utilization Review Specialist based in the United States.

Join a healthcare team dedicated to improving utilization management, strengthening reimbursement outcomes, and ensuring compliance with clinical and payer requirements. In this remote role, you will oversee admission and concurrent utilization reviews, identify potential reimbursement denials, and coordinate appeals to support appropriate patient care and financial performance. You will apply your clinical nursing expertise to evaluate medical records, assess medical necessity, and develop evidence-based appeals. Working closely with case managers, physicians, medical directors, and payer representatives, you will help resolve complex cases and improve review processes. Your work will contribute to quality improvement initiatives, timely appeal resolutions, and more effective healthcare administration. This opportunity is ideal for an experienced nursing professional who combines clinical judgment, analytical thinking, and strong communication skills in a fast-paced, independent working environment.