Contingent UR/LTSS Registered Nurse

About the role

This fully remote position supports Michigan Medicaid programs by conducting Nursing Facility Level of Care (LOC) reviews and Home Help quality review assessments.

• 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.
• Cover 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.

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. 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. 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.

Qualifications

Minimum qualifications include:

• 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.
• 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.

Skills

Strong 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.

Benefits

Flexible, contingent work schedule. Minimum availability of 4–8 hours per week is required to maintain program engagement. Additional hours may be available based on workload and program needs. Most work is completed during normal business hours. Occasional evening, weekend, or holiday work may be required to meet operational deadlines.

Pay

Negotiable based on experience and qualifications.

Schedule

Fully remote, contingent position. Most work is completed during normal business hours. Occasional evening, weekend, or holiday work may be required to meet operational deadlines.