Case Manager – Utilization Review Specialist

Quorum Health

. Assume responsibility and accountability for admission and concurrent reviews to prevent payer denials .

Posted 10/27/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in case management, utilization review, and appeals processes, with a strong focus on compliance with regulatory standards and payer requirements. Proficient in analyzing clinical records and applying criteria for admission and treatment decisions.

Highest-signal resume keywords

Current RN LicenseCase Management ExperienceUtilization Review KnowledgeInterQual Level of Care CriteriaExcellent Technical Writing Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Record AnalysisData AbstractionQuality Assurance ReviewsAppeal ManagementRegulatory ComplianceMedical Necessity ReviewPatient Admission ReviewStatistical ReportingDecision-MakingDischarge Planning

Soft Skills

Critical EvaluationFlexibilityAdaptabilityInterpersonal CommunicationConfidentiality Maintenance

Tools & Technologies

Billing SystemsDatabase ManagementClinical Reference Libraries

Certifications & Qualifications

State-Issued RN License

Industry Keywords

HealthcarePayer RegulationsQuality ImprovementHIPAA ComplianceThird Party Payer

About the role

Key responsibilities & impact

Assume responsibility and accountability for admission and concurrent reviews to prevent payer denials
Appeal accounts reviewed and deemed appropriate for appeal
Identify denial trends and create structures to resolve root causes through workflow improvements
Analyze patient records to determine legitimacy of admission, treatment, and length of stay
Analyze insurance, governmental, and accrediting agency standards
Review patient admission applications and approve admissions or refer cases to utilization review committees
Compare inpatient medical records with established criteria and consult medical, nursing, and professional staff
Abstract data from records and maintain statistics
Determine patient review dates according to diagnostic criteria
Assist with federally mandated quality assurance reviews
Research clinical records, insurance regulations, and claim history to determine next steps
Monitor compliance with appeal decision time frames and collaborate with departments to resolve issues
Review records for completeness and determine administrative or clinical appeal
Assign reviews requiring medical necessity review to physician advisors and medical directors
Coordinate first-, second-, and third-level appeals
Consult with managers and interface with case managers, clinical supervisors, account managers, and other personnel
Document denials in billing systems and track outcomes for reporting
Manage appeals and monitor appeal volume to engage additional resources
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
Prepare for and complete appeals audits
Monitor and report Quality Improvement activities
Draft professional appeal letters using supporting documents, policies, and statutes
Perform other duties as assigned

Requirements

What you’ll need

Current state-issued RN license
Significant experience in the healthcare field
Minimum of five years as a clinical nurse in an acute care setting
At least five to seven years of experience in case management, discharge planning, and/or utilization review preferred
Knowledge of InterQual Level of Care Criteria and Milliman & Robertson Criteria preferred
Knowledge of third party payer regulations related to utilization and quality review preferred
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 pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support clinical appeals arguments
Maintains 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 and technical writing and typing skills
Flexibility and willingness to learn and adapt to changes in regulations and task-related priorities
Ability to work independently and adapt quickly to changing priorities and regulations
Must reside in Arkansas, California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Utah, Tennessee, Texas, or Wyoming