Curae Finance, LLC reduces the risk of uncompensated care and lost revenue for providers while making care more affordable for patients, improving the overall patient financial experience, and increasing net promoter scores. As the national leader in non-recourse healthcare financing for consumers, headquartered in Atlanta, Georgia, Curae’s Patient Financial Access platform reduces unpaid balances across all patient coverage scenarios, decreasing patient bad debt by 20% or more and delivering game-changing revenue. With over $100MM in funding delivered to providers to date and rapid growth to serve healthcare systems nationwide, Fortune Magazine has recognized our parent company as one of Fortune’s 100 Fastest-Growing Companies for three consecutive years: #1 in 2021, #4 in 2022, and #28 in 2023.

Position Overview

We are seeking an experienced Clinical Case Manager / Utilization Review Specialist to perform comprehensive medical record reviews and determine patient appropriateness for an insurance-related program. This role centers on holistic assessment of the entire patient chart—including diagnoses, problem lists, provider notes, prior encounters, medications, and treatment history—to evaluate clinical complexity, anticipated medical needs, and alignment with program eligibility criteria.

While ICD-10 codes are reviewed as part of the process, this role requires the ability to synthesize information across the full medical record and apply sound clinical reasoning beyond surface-level coding. The successful candidate may come from nursing, social work, medical assisting, or a closely related case-management background, provided they have the depth of medical experience and judgment required for independent chart review. This is a full-time hybrid role with a preference for candidates based in Atlanta.

Key Responsibilities

Comprehensive Medical Record Review & Clinical Assessment

• Conduct end-to-end reviews of patient medical records, including diagnoses, problem lists, provider notes, prior visits, medications, and treatment plans.
• Evaluate whether the full clinical record accurately reflects disease burden, acuity, comorbidities, and overall patient complexity.
• Identify gaps, inconsistencies, or ambiguities across documentation that impact clinical understanding or eligibility determination.
• Use ICD-10 codes as a reference point while validating diagnoses against the broader clinical narrative.
• Request additional documentation or clarification when the medical record does not sufficiently support clinical conclusions.

Utilization Review & Eligibility Determination

• Analyze submitted diagnoses for alignment with internal eligibility thresholds and criteria.
• Assess anticipated medical needs, utilization risk, and potential cost drivers associated with each diagnosis.
• Document approval or denial decisions with clear, defensible clinical rationale.
• Collaborate with cross-functional partners to refine and improve internal scoring and eligibility criteria based on clinical findings.

Clinical Needs Assessment & Utilization Risk Evaluation

• Assess anticipated medical utilization, treatment intensity, and potential cost drivers based on longitudinal chart review.
• Evaluate potential complications, disease progression, and long-term care considerations.
• Determine whether documented conditions and treatments align with program eligibility thresholds and intent.
• Apply independent clinical judgment to approve or deny cases, documenting clear and defensible rationale.

Quality Assurance & Documentation Integrity

• Ensure accuracy, consistency, and integrity across all clinical reviews and determinations.
• Identify patterns of miscoding, vague documentation, or incomplete clinical submissions.
• Maintain thorough review logs and standardized documentation to support audit readiness and quality improvement.

Required Qualifications

• One of the following professional pathways:
• Registered Nurse (RN) with an active, unrestricted license; or
  • Licensed Practical/Vocational Nurse (LPN/LVN) with an active, unrestricted license and substantial case management, utilization review, oncology, or complex chronic-care experience; or
  • Licensed or license-eligible social worker (e.g., LMSW/LCSW or state equivalent) with healthcare case management experience involving medically complex populations; or
  • Certified or Registered Medical Assistant (CMA/RMA) with extensive experience in clinical case management, oncology navigation, utilization review, or complex chronic-disease care.
• At least 5 years of healthcare experience, including 3 or more years in case management, utilization review/utilization management, clinical documentation review, patient navigation, or another role requiring longitudinal medical-record review.
• Direct experience with oncology and complex chronic diseases, including the ability to recognize treatment intensity, disease progression, complications, and likely next steps in care.
• Experience navigating and reviewing records across multiple electronic medical record systems; Epic and MEDITECH experience strongly preferred.
• Working knowledge of Medicare and Medicaid eligibility pathways, including how age, disability, ESRD, pregnancy, income, and state-specific requirements may affect coverage options.
• Demonstrated critical thinking and clinical reasoning, including the ability to anticipate future treatment, utilization, and care needs from diagnoses, provider notes, medications, prior encounters, and documented care plans.
• Ability to distinguish active treatment from surveillance, routine follow-up, maintenance-only care, or completed treatment.
• Ability to identify missing, conflicting, or insufficient documentation and determine what clarification is needed before making a recommendation.
• Strong understanding of how diagnoses, provider documentation, medications, procedures, and treatment history interrelate, including working knowledge of ICD-10 and common clinical terminology.
• Ability to make consistent, independent recommendations within established criteria and clearly document a concise, defensible rationale.
• Strong written and verbal communication skills and the ability to collaborate with clinical and non-clinical teams in a hybrid work environment.

Preferred Qualifications

• Strongly preferred: 3+ years of oncology, infusion, oncology navigation, or cancer case-management experience.
• Experience managing or reviewing patients with complex chronic conditions such as heart failure, COPD, cirrhosis, CKD, sickle cell disease, or transplant-related care.
• Experience in acute care, hospital case management, payer utilization management, clinical documentation integrity, specialty care coordination, or financial/coverage navigation.
• Experience reviewing clinical documentation for reimbursement, medical necessity, utilization, risk assessment, insurance eligibility, or program qualification.
• Relevant certification such as ACM, CCM, CCDS, OCN, oncology patient navigator certification, social work case-management certification, or an equivalent credential.

Recommended Interview Evidence

• Walk through a de-identified complex oncology or chronic-disease case and explain the likely next treatment steps and utilization risks.
• Review a short sample chart and identify active treatment, missing documentation, coverage considerations, and the rationale for a recommendation.
• Demonstrate practical knowledge of Epic and/or MEDITECH workflows, including locating provider notes, treatment plans, encounters, medications, and insurance information.
• Explain when Medicare or Medicaid may be a more appropriate coverage pathway and when additional eligibility verification is needed.
• Provide examples of independent decisions, escalations, and concise written documentation that were clinically defensible and consistent with policy.

Position Details

• Employment Type: Full-Time
• Location: Atlanta (Preferred) or Hybrid
• Primary Function: Comprehensive clinical review of patient cases to determine program eligibility and anticipate future care needs