100% Remote | Full-Time | Contract-to-Hire
The opportunityEvery independent review represents a person seeking access to care or essential services. At RediMinds, we combine technology-enabled workflows with the judgment of independent clinicians to help deliver fair, well-supported, and timely determinations.
We are adding Case Review Managers to safeguard quality at two critical points: when a case enters our system and before the final determination is issued. Much of the administrative workflow is automated. Your judgment, attention to detail, and clear writing ensure the information is right, discrepancies are resolved, and each determination is complete and ready for release.
What you will do- Review incoming case files for completeness and accuracy, including case 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 the underlying record, escalating discrepancies and ensuring a reliable foundation for clinician review.
- Quality-check clinicians' written reviews for completeness, internal consistency, clear rationale, accurate references to supporting evidence, and responsiveness to the question under review.
- Work directly with clinicians to clarify or correct gaps in documentation while preserving their independent clinical judgment and decision-making authority.
- Perform final quality assurance on determination letters, ensuring they faithfully reflect the clinician's findings, are clear and professional, and meet applicable case-specific requirements before issuance.
- 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 you bring - required- 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; able to make complex, sensitive determinations clear, accurate, and consistent.
- Exceptional attention to detail, sound judgment, and the 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 the importance of impartial, well-documented healthcare review processes.
- Bachelor's degree in a healthcare-related field or an equivalent combination of education and relevant experience.
Especially valuable - not required- Direct experience with an Independent Review Organization (IRO), external grievance reviews, or external healthcare appeals.
- Experience with Pennsylvania Personal Assistance Services (PAS) cases is especially valuable; 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.
How we workThis is a fully remote, self-directed role with close collaboration across clinical and operations teams. Evening or weekend work may be required when needed to meet regulatory deadlines. The Case Review Manager is accountable for documentation and process quality; independent clinicians remain responsible for clinical determinations.
The pay range for this role is:
85,000 - 95,000 USD per year (United States)
