Remote Utilization Review Jobs in Newark, NJ (NOW HIRING)

Remote | Utilization Management & Case Management Clinical Review ConsultantWe are sharing a specialised part-time consulting opportunity for United States-based healthcare professionals experienced in utilization management, case management, medical necessity review, care coordination, discharge planning, clinical review criteria, physician advisor workflows, and healthcare operations leadership.

This role supports current and upcoming remote consulting opportunities focused on AI-assisted healthcare review, utilization management evaluation, case management workflow assessment, clinical documentation review, and high-quality project execution. Selected professionals will apply clinical and operational expertise to evaluate medical necessity determinations, review AI-generated utilization management outputs, assess care coordination workflows, and provide structured feedback based on detailed project criteria.

Key ResponsibilitiesProfessionals in this role may contribute to: Review utilization management and case management workflows involving concurrent review, retrospective review, discharge planning, care coordination, and level-of-care determinationsEvaluate AI-generated medical necessity determinations, clinical review outputs, and decision-support recommendations for accuracy and clinical appropriatenessApply InterQual, MCG, Milliman, or similar clinical review criteria to support admission, continued stay, observation status, and inpatient determinationsAssess clinical documentation, review logic, and care pathway recommendations against professional utilization management standardsReview complex utilization management cases involving peer-to-peer review requests, denial appeals, payer communication, and physician advisor escalationEvaluate workflows related to care transitions, post-acute coordination, discharge planning, and collaboration between clinical teams, payers, and providersAssess operational indicators such as avoidable days, denial rates, observation versus inpatient conversion, readmission risk, and utilization performanceIdentify gaps, inconsistencies, edge cases, or unsupported conclusions in clinical review and case management outputsAnnotate AI-generated healthcare outputs and provide structured feedback to support clinical review qualityExplain review decisions with consistency, attention to detail, and professional clinical judgmentApply CMS Conditions of Participation, Two-Midnight Rule, payer-specific requirements, and utilization management best practices where relevantCollaborate through structured project workflows involving clinical, operational, compliance, and healthcare technology reviewIdeal ProfileStrong candidates may have:5+ years of experience in utilization management, case management, clinical review, or healthcare operationsAt least 2 years of leadership experience in utilization management, case management, physician advisor operations, or related clinical review functionsActive clinical licensure, with a Registered Nurse license required for nursing leadership profilesPhysician advisor, MD, or DO experience may be especially relevant for physician advisor-focused workflowsStrong medical necessity review expertise and deep familiarity with clinical review criteriaExceptional written and verbal English communication skillsHigh attention to detail and ability to critically evaluate clinical documentation, workflow logic, and AI-generated healthcare outputsAbility to work independently in a remote, project-based environmentEducational BackgroundActive Registered Nurse licensure is required for Registered Nurse utilization management or case management leadership profilesMD or DO background with physician advisor, utilization management, or clinical review experience may be preferred for physician advisor-focused rolesProfessional experience in health systems, hospitals, payer environments, accountable care organizations, value-based care organizations, or clinical operations teams is highly relevantBackgrounds in utilization management leadership, case management management, clinical documentation review, revenue cycle collaboration, denial management, or care coordination may support project fitNice to HaveCPUR, ACM, CCM, or similar utilization review, case management, or clinical operations credentialExperience managing physician advisor programs, peer-to-peer review processes, denial appeals, or complex medical necessity casesFamiliarity with utilization management platforms, clinical review software, EHR systems, or related healthcare operations toolsExperience with CMS Two-Midnight Rule, observation status regulations, inpatient criteria, payer policies, and compliance requirementsExposure to healthcare technology, AI-assisted clinical tools, digital health workflows, or structured annotation and review processesBackground in health system, accountable care, value-based care, or payer-facing utilization management programsWhy This OpportunityApply utilization management and case management leadership expertise to structured remote healthcare review workContribute to high-quality AI-assisted clinical review and medical necessity evaluation workflowsUse operational judgment, clinical review criteria, and care coordination experience in a focused evaluation environmentWork on flexible assignments aligned with healthcare operations, utilization performance, case review, and clinical decision-support expertiseRemote structure with competitive hourly compensationContract DetailsIndependent contractor roleFully remote with flexible schedulingUnited States-based professionals are required for this opportunityPart-time project-based commitment depending on availability, onboarding status, and project needsCompetitive rates of $80–$120 per hour depending on clinical background, leadership experience, utilization management expertise, and project scopeWeekly payments via Stripe or WiseProjects may be extended, shortened, or adjusted depending on scope and performanceWork will not involve access to confidential or proprietary information from any employer, client, or institutionThis opportunity is available through 24-MAG LLC. We connect experienced professionals with remote consulting opportunities across technical, evaluation, and project-based workstreams.