Contingent Registered Nurse, UR/LTSS

This is a fully remote position, open to applicants in Michigan.

📋 Description

• Execute utilization review tasks in alignment with program specifications, contractual commitments, clinical protocols, and regulatory standards.

• Carry out telephonic Nursing Facility Level of Care (LOC) assessments for beneficiaries of Michigan Medicaid.

• Conduct verification, secondary reviews, and quality assessments for Long-Term Services & Supports (LTSS) cases.

• Facilitate virtual Home Help evaluations utilizing Microsoft Teams.

• Assess medical records, evaluations, care plans, and relevant clinical documentation to ascertain eligibility and medical necessity.

• Implement evidence-based clinical criteria and state regulations to substantiate review conclusions.

• Oversee cases from initiation to resolution while adhering to established turnaround times.

• Accurately document review outcomes within secure electronic systems and state portals.

• Liaise with providers, beneficiaries, and internal staff concerning review outcomes and requests for additional information.

• Engage in administrative hearings and appeals to advocate for review determinations when necessary.

• Stay informed on contractual obligations, Medicaid regulations, and applicable clinical standards.

• Adhere to HIPAA, FISMA, URAC, CMS, organizational policies, and security protocols.

• Participate in mandatory training, calibration, and quality assurance initiatives.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• A valid and unrestricted Michigan Registered Nurse (RN) license is required.

• Experience in Long-Term Care/LTSS is essential.

• Prior experience in Utilization Review (UR) and/or Utilization Management (UM) is necessary.

• A minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS is required.

• Equivalent experience may be accepted in lieu of a bachelor's degree.

• Familiarity with Michigan Medicaid or other state-specific healthcare contracts is preferred.

• Strong understanding of Medicare, Medicaid, Long-Term Services & Supports (LTSS), Nursing Facility Level of Care (LOC) assessments, and long-term care regulations is advantageous.

• Exceptional clinical assessment, critical thinking, analytical, and documentation capabilities are essential.

• Strong written, verbal, and interpersonal communication skills, including the ability to articulate and support clinical review conclusions, are required.

• Proficiency in electronic health records, secure web-based platforms, and Microsoft Office applications, including Outlook, Teams, Word, and Excel, is necessary.

• Capacity to work independently in a remote setting while consistently meeting productivity, quality, and timeliness standards is essential.

• A minimum availability of 4–8 hours per week is required.

• Occasional evening, weekend, or holiday work may be necessary.

🏝️ Benefits

• 100% remote work opportunity.

• Flexible contingent work schedule.

• Potential for additional hours based on program requirements.

• Engaging clinical practice that supports healthcare quality and outcomes.

• Involvement in mandatory training, calibration, and quality assurance initiatives.