Registered Nurse – Contingent

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

📋 Description

• Carry out utilization review tasks in alignment with program specifications, contractual commitments, clinical protocols, and regulatory requirements.

• Execute telephonic Nursing Facility Level of Care (LOC) assessments for Michigan Medicaid recipients utilizing established LTSS standards.

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

• Facilitate virtual Home Help evaluations via Microsoft Teams for beneficiaries selected by MDHHS.

• Analyze medical records, assessments, care plans, and supporting clinical documents to ascertain eligibility and medical necessity.

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

• Employ a case management methodology from the point of case assignment to completion, adhering to established turnaround times.

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

• Liaise with providers, beneficiaries, and internal personnel regarding review outcomes and requests for supplementary information.

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

• Stay updated on contractual obligations, Medicaid regulations, and relevant clinical guidelines.

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

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

• Execute additional responsibilities as assigned.

⛳️ Requirements

• Must possess an active, unrestricted Michigan Registered Nurse (RN) license.

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

• Experience in Utilization Review (UR) and/or Utilization Management (UM) is mandatory.

• 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 considered in lieu of a bachelor’s degree.

• Familiarity with Michigan Medicaid or other state-based 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.

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

• Strong written, verbal, and interpersonal communication skills, including the ability to articulate and justify clinical review decisions, are essential.

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

• Ability to work autonomously in a remote setting while consistently meeting productivity, quality, and timeliness expectations.

• Availability of at least 4–8 hours per week is required.

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

🏝️ Benefits

• 100% remote work from anywhere within the United States.

• Flexible, contingent work schedule.

• Opportunities for additional hours based on program requirements.

• Engaging clinical practice that enhances healthcare quality and outcomes.

• Participation in necessary training, calibration, and quality assurance activities.