Contingent UR/LTSS Registered Nurse
About The Position
iMPROve Health is seeking an experienced Michigan-licensed Registered Nurse (RN) to join their team as a Contingent Utilization Review / Long-Term Services & Supports (UR/LTSS) Review Nurse. This fully remote position supports Michigan Medicaid programs by conducting Nursing Facility Level of Care (LOC) reviews and Home Help quality review assessments. This role is ideal for experienced nurses with both Utilization Review/Utilization Management (UR/UM) and Long-Term Services & Supports (LTSS)/Long-Term Care experience who are looking for flexible, contingent work while remaining engaged in meaningful clinical practice. Review nurses evaluate medical records, conduct telephonic and virtual assessments, apply established clinical and regulatory criteria, and ensure timely, accurate review determinations. This position also includes participation in administrative hearings and appeals when necessary. Contingent nurses are expected to maintain regular availability of at least 4–8 hours per week, with opportunities for additional hours based on program needs. Most work is performed during normal business hours; however, occasional evening, weekend, or holiday work may be required.
Requirements
- Active, unrestricted Michigan Registered Nurse (RN) license required.
- Long-Term Care/LTSS experience is required.
- Utilization Review (UR) and/or Utilization Management (UM) experience is required.
- Minimum of 3–5 years of combined experience in utilization review/utilization management and long-term care or LTSS.
- Excellent clinical assessment, critical thinking, analytical, and documentation skills.
- Strong written, verbal, and interpersonal communication skills, including the ability to explain and defend clinical review determinations.
- Experience with electronic health records, secure web-based portals, and Microsoft Office applications, including Outlook, Teams, Word, and Excel.
- Ability to work independently in a remote environment while consistently meeting productivity, quality, and timeliness expectations.
Nice To Haves
- Bachelor’s degree in nursing preferred. Equivalent experience may be considered in lieu of a bachelor's degree.
- Experience working with Michigan Medicaid or other state-based healthcare contracts preferred.
- Strong knowledge of Medicare, Medicaid, Long-Term Services & Supports (LTSS), Nursing Facility Level of Care (LOC) determinations, and long-term care regulations preferred.
Responsibilities
- Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards.
- Conduct telephonic Nursing Facility Level of Care (LOC) reviews for Michigan Medicaid beneficiaries using established LTSS criteria.
- Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases.
- Conduct virtual Home Help assessments using Microsoft Teams for beneficiaries selected by the Michigan Department of Health and Human Services (MDHHS).
- Review medical records, assessments, care plans, and supporting clinical documentation to determine eligibility and medical necessity.
- Apply evidence-based clinical criteria and state regulations to support review determinations.
- Utilize a case management approach from case assignment through completion while meeting established turnaround times.
- Document review findings accurately, thoroughly, and professionally within secure electronic systems and state portals.
- Communicate effectively with providers, beneficiaries, and internal staff regarding review findings and requests for additional information.
- Participate in administrative hearings and appeals to represent review determinations when required.
- Maintain current knowledge of contractual requirements, Medicaid regulations, and applicable clinical guidelines.
- Comply with all applicable HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements.
- Participate in required training, calibration, and quality assurance activities.
- Perform other duties as assigned.
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What This Job Offers
Career Level
Mid Level
Education Level
Associate degree
