Contingent UR/LTSS Registered Nurse

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

📋 Description

• Execute utilization review processes in alignment with program requirements, contractual obligations, clinical guidelines, and regulatory standards.

• Perform telephonic Nursing Facility Level of Care (LOC) assessments for Michigan Medicaid beneficiaries utilizing established LTSS criteria.

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

• Conduct virtual Home Help assessments via Microsoft Teams for beneficiaries designated by the Michigan Department of Health and Human Services (MDHHS).

• Analyze medical records, assessments, care plans, and supporting clinical documentation to evaluate eligibility and medical necessity.

• Employ evidence-based clinical criteria and state regulations to substantiate review determinations.

• Implement a case management approach from case assignment through to completion, ensuring adherence to established turnaround times.

• Accurately, thoroughly, and professionally document review findings within secure electronic systems and state portals.

• Effectively communicate with providers, beneficiaries, and internal staff regarding review outcomes and requests for additional information.

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

⛳️ Requirements

• A valid, unrestricted Michigan Registered Nurse (RN) license is mandatory.

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

• Previous experience in Utilization Review (UR) and/or Utilization Management (UM) is required.

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

• A Bachelor's degree in nursing is preferred; equivalent experience may be accepted in place of a degree.

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

• Excellent clinical assessment, critical thinking, analytical, and documentation skills are required.

• Strong written, verbal, and interpersonal communication skills, including the ability to articulate and defend clinical review determinations.

• Familiarity with electronic health records, secure web-based portals, and Microsoft Office applications, such as Outlook, Teams, Word, and Excel.

• Capability to work independently in a remote setting while continuously meeting productivity, quality, and timeliness standards.

🏝️ Benefits

• Flexible work arrangements

• Professional development