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Assistant Remote Utilization Review Jobs in Pennsylvania

Dane Street, LLC

... Record Reviews. This is a fully remote opportunity offering flexible scheduling, allowing you to ... Enhanced industry expertise in medical necessity, utilization review, and claims support * Expanded ...

Prestige

LPN Case Manager

PA · Remote

$75K/yr

... utilization review * Facilitate timely and safe discharge planning * Serve as primary point of ... This is a Remote Position. * Competitive Rate * Medical, Dental, and Vision Insurance * 401K ...

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Assistant Remote Utilization Review information

What is the difference between Assistant Remote Utilization Review vs Utilization Review Nurse?

AspectAssistant Remote Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, certification in case management or utilization reviewRegistered Nurse (RN) license, often with additional certifications in case management or utilization review
Work EnvironmentRemote, administrative setting, telehealth or telecommutingRemote or hospital/clinic settings, primarily telehealth or administrative
Employer & IndustryHealth insurance companies, managed care organizations, healthcare providersHospitals, insurance companies, healthcare organizations

Both roles involve reviewing patient cases to determine appropriate care and resource utilization. The Assistant Remote Utilization Review typically supports the process with administrative tasks and basic review, while the Utilization Review Nurse performs more in-depth clinical assessments. Both require nursing credentials and often work remotely within healthcare or insurance industries.

What are the most commonly searched types of Remote Utilization Review jobs in Pennsylvania?

The most popular types of Remote Utilization Review jobs in Pennsylvania are:

What are popular job titles related to Assistant Remote Utilization Review jobs in Pennsylvania?

For Assistant Remote Utilization Review jobs in Pennsylvania, the most frequently searched job titles are:

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The top searched job categories for Assistant Remote Utilization Review jobs in Pennsylvania are:

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Cities in Pennsylvania with the most Assistant Remote Utilization Review job openings:

Assistant Remote Utilization Review jobs near you
Infographic showing various Assistant Remote Utilization Review job openings in Pennsylvania as of August 2026, with employment types broken down into 83% Full Time, and 17% Part Time. Highlights an 100% Remote job distribution.

Clinical Appeals Nurse - Full Time Remote - Jefferson Health

Philadelphia, PA • On-site, Remote

Thomas Jefferson University Hospitals, Inc.
Hospitals • 10K+ employees

7.6

Company rating: 7.6 out of 10

Based on 350 frontline employees who took The Breakroom Quiz

191st of 893 rated healthcare providers

People enjoy working here

Good employer

Recommended by students

Learn more about Thomas Jefferson University Hospitals, Inc.external

Full-time

Medical, Dental, Vision, Life, Retirement

Re-posted 18 days ago

Job description

Job Details
Reviews payor denials and audits for potential lost revenue. Writes comprehensive, factual arguments to present to third-party payers, medical review boards, or other responsible parties applying clinical criteria to establish medical necessity. Functions as a hospital liaison with external third-party payors to appeal denied claims. Works closely with Physician advisor team to facilitate appeals to payors. Monitors and reports payor trends to management team.
Job Description
Clinical Appeals Nurse - Full Time Remote - Jefferson Health
Articulates the job's main responsibilities. This is not intended to be an exhaustive list of all essential functions or all duties performed. The essential functions listed below and percentage of time may vary between departments and locations, and are subject to change based on management discretion and organizational needs. Other responsibilities may be assigned at the discretion of management to meet organizational needs.
  • Creates an appeal letter to uphold the procedure based on medical policy guidelines of the payor and the documentation found in the hospital/physician information system.
  • Facilitates write off accounts that cannot provide adequate medical necessity or documentation for the payor to meet their guidelines.
  • Investigates and coordinates completion of patient records required to retrospectively precertify accounts and appeal insurance denials.
  • Contacts insurance companies and conducts appeals via telephone or email.
  • Coordinates appeals that need a physician's input for the payor and writes off claims that have no further appeal rights.
  • Identifies areas for revenue loss due to documentation or processes not being reimbursable thru payors.
  • Ensures that all appeals are sent to the correct payor within the appeal guidelines.
  • Ensures compliance with regulatory and accrediting requirements.
  • Reviews claim documentation and pulls supporting medical documentation from the system to support the medical policy guidelines of the payor.
  • Searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

Qualifications:
The requirements listed below are representative of the knowledge, skill, and/or ability required or preferred.
Education - Required
  • Bachelor's Degree Nursing or
  • Specialized Diploma

Experience - Required
  • 10 years of clinical or case management/utilization review experience

Knowledge, Skills and Abilities - Required
  • Ability to read medical charts and identify deficiencies in documentation content.
  • Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
  • Knowledge of Interqual/medical policy criteria, case management principles, utilization review, and hospital departmental procedures.
  • Knowledge of coding for payment of claims.
  • Insurance knowledge of payors and their unique rules.
  • Epic workflow experience with notes in account history and WQ workflows.
  • Intermediate Excel and MS Word experience.
  • Must complete RCE Training and pass test with 80% or better.

Licenses and Certifications - Required
  • RN - Licensed Registered Nurse_PA - State of Pennsylvania

Work Shift
Workday Day (United States of America)
Worker Sub Type
Regular
Employee Entity
Thomas Jefferson University
Primary Location Address
1101 Market, Philadelphia, Pennsylvania, United States of America
Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.
Benefits
Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
For more benefits information, please click here
Jefferson Health logo

About Jefferson Health

Sourced by ZipRecruiter

Jefferson Health is a revered name in the healthcare sector, based in Philadelphia, Pennsylvania, US. This nonprofit health system is dedicated to delivering high-quality, compassionate clinical care and services across the region. The organization was founded in 1824 as Jefferson Medical College, and over the years, it has grown into a vast network of physicians and specialists, hospitals, outpatient and urgent care facilities. Offering a comprehensive range of healthcare services, Jefferson Health covers areas including cancer care, neuroscience, orthopedics, and cardiovascular care, among others. The organization's mission is to improve lives by promoting overall health and wellness, emphasizing value-based care, and making innovative medical advancements. Besides, one of their notable achievements includes being recognized by the National Academy of Medicine as a national leader in patient safety improvements.

Industry

Hospitals and health care and social assistance

Company size

10,000+ Employees

Headquarters location

Philadelphia, PA, US

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Pay

Benefits

Hours and flexibility

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